GUIA DE SERVIÇO PROFISSIONAL / SERVIÇO AUXILIAR DE DIAGNÓSTICO E TERAPIA - SP/SADT 1 - Registro ANS

3 - Nº Guia Principal

4 - Data da Autorização

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

5-Senha

6 - Data Validade da Senha

|___|___| / |___|___| / |___|___|

2- Nº

7 - Data de Emissão da Guia

|___|___| / |___|___| / |___|___|

|___|___| / |___|___| / |___|___|

Dados do Beneficiário 8 - Número da Carteira

9- Plano

10 - Validade da Carteira

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

11 - Nome

12 - Número do Cartão Nacional de Saúde

|___|___| / |___|___| / |___|___|

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Dados do Contratado Solicitante 13 - Código na Operadora / CNPJ / CPF

14 - Nome do Contratado

15 - Código CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| 16 - Nome do Profissional Solicitante

17 - Conselho Profissional

18 - Número no Conselho

19 - UF

20 - Código CBO S

Dados da Solicitação / Procedimentos e Exames Solicitados 21 - Data/Hora da Solicitação

22 - Caráter da Solicitação

|___|___| / |___|___| / |___|___| 25-Tabela

|___|___|:|___|___|

23 - CID 10

|___| E-Eletiva U-Urgência/Emergência

26- Código do Procedimento

24 - Indicação Clínica (obrigatório se pequena cirurgia, terapia, consulta de referência e alto custo)

|___|___|___|___|___|

27 - Descrição

28.Qt.Solic. 29-Qt.Autoriz.

1-

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__________________________________________________________________ __________________________________________________________________________________________________________

|___|___|

| ___|___|

2-

|___|___| |___|___|___|___|___|___|___|___|___|___|

__________________________________________________________________ __________________________________________________________________________________________________________

|___|___|

| ___|___|

3-

|___|___| |___|___|___|___|___|___|___|___|___|___|

__________________________________________________________________ __________________________________________________________________________________________________________

|___|___|

| ___|___|

4-

|___|___| |___|___|___|___|___|___|___|___|___|___|

__________________________________________________________________ __________________________________________________________________________________________________________

|___|___|

| ___|___|

5-

|___|___| |___|___|___|___|___|___|___|___|___|___|

__________________________________________________________________ __________________________________________________________________________________________________________

|___|___|

| ___|___|

Dados do Contratado Executante 30 - Código na Operadora / CNPJ / CPF

31 - Nome do Contratado

32-T.L.

33-34-35-Logradouro - Número - Complemento

41 - Nome do Profissional Executante/Complementar

42 - Conselho Profissional

36 - Município

37 - UF

38 - Cód. IBGE

39 - CEP

40- Código CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___| 40a - Código na Operadora / CPF do exec. complementar

43 - Número no Conselho

44 - UF

45 - Código CBO S

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

45a - Grau de Participação

|___|___|

Dados do Atendimento 46-Tipo Atendimento

|___|___|

01 - Remoção 02 - Pequena Cirurgia 03 - Terapias 04 - Consulta 05- Exame 06-Atendimento Domiciliar 07- SADT Internado 08 - Quimioterapia 09-Radioterapia 10-TRS-Terapia Renal Substitutiva

47 - Indicação de Acidente

48- Tipo de Saída

|___| 0 - Acidente ou doença relacionado ao trabalho 1 - Trânsito 2 - Outros

|___| - 1-Retorno

2-Retorno SADT

3-Referência

4-Internação

5-Alta

6-Óbito

Consulta Referência 49 -Tipo de Doença

50 -Tempo de Doença

|___| A-Aguda C-Crônica

|___|___| - |__| A-Anos M-Meses D-Dias

Procedimentos e Exames realizados 51-Data

52-Hora Inicial

53-Hora Final

54-Tabela

55-Código do Procedimento

56-Descrição

57-Qtde.

58-Via 59-Tec. 60% Red. / Acresc.

61-Valor Unitário - R$

62-Valor Total - R$

1-|___|___|/|___|___|/|___|___|

|___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|__ _| _____________________________________________________ |___|___| |___| |___|

|___| ___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2-|___|___|/|___|___|/|___|___|

|___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|__ _| _____________________________________________________ |___|___| |___| |___|

|___|___|___|,|___|___| |___|___|___|___ |___|,|___|___| |___|___|___|___|___|,|___|___|

3-|___|___|/|___|___|/|___|___|

|___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|__ _| _____________________________________________________ |___|___| |___| |___|

|___|___|___|,|___|___| |___|___|___|___ |___|,|___|___| |___|___|___|___|___|,|___|___|

4-|___|___|/|___|___|/|___|___|

|___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|__ _| _____________________________________________________ |___|___| |___| |___|

|___|___|___|,|___|___| |___|___|___|___ |___|,|___|___| |___|___|___|___|___|,|___|___|

5-|___|___|/|___|___|/|___|___|

|___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|__ _| _____________________________________________________ |___|___| |___| |___|

|___|___|___|,|___|___| |___|___|___|___ |___|,|___|___| |___|___|___|___|___|,|___|___|

63-Data e Assinatura de Procedimentos em Série

1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________

9 - |___|___|/|___|___|/|___|___| ______________________

2 - |___|___|/|___|___|/|___|___| _________________________ 4 - |___|___|/|___|___|/|___|___| _________________________ 6 - |___|___|/|___|___|/|___|___| ______________________ 8 - |___|___|/|___|___|/|___|___| ______________________ 10 - |___|___|/|___|___|/|___|___| ______________________ 64 - Observação

_____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ 65 - Total Procedimentos R$

|___|___|___|___|___|___|___|,|___|___| 86 - Data e Assinatura do Solicitante

|___|___| / |___|___| / |___|___|

66 - Total Taxas e Aluguéis R$

67- Total Materiais R$

|___|___|__ _|___|___|___|___|,|___|___|

|___|___|___|___|___|___|___|,|___|___|

87 - Data e Assinatura do Responsável pela Autorização

|___|___| / |___|___| / |___|___|

68 - Total Medicamentos R$

69 - Total Diárias R$

|___|___|___|___|___|___|___|,|___|___|

|___|___|___|___|___|___|___|,|___|___|

88-Data e Assinatura do Beneficiário ou Responsável

|___|___|/|___|___|/|___|___|

70 - Total Gases Medicinais R$

|___|___|__ _|___|___|___|___|,|___|___|

71 - Total Geral da Guia R$

|___|___|___|__ _|___|___|___|___|,|___|___|

89- Data e Assinatura do Prestador Executante

|___|___|/|___|___|/|___|___|

Guia SP-SADT.pdf

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