Hapvida - Guia SP/SADT

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

2- Nº 13087690

1 - Registro ANS

3 - Nº Guia Principal

4 - Data da Autorização

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5 - Senha

6 - Data de Validade da Senha

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7 - Data de Emissão da Guia

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DADOS DO BENEFICIÁRIO

8 - Número da Carteira

9 - Plano

10 - Validade da Carteira

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11 - Nome

12 - Número do Cartão Nacional de Saúde

DADOS DO CONTRATADO SOLICITANTE

13 - Código na Operadora / CNPJ / CPF

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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

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22 - Caráter da Solicitação

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E - Eletiva U - Urgência / Emergência

23 - CID 10

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24 - Indicação Clínica

25 - Tabela

26 - Código do Procedimento

27 - Descrição

28-Qtde.Solic.

29-Qtde.Autor.

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DADOS DO CONTRATADO EXECUTANTE

30 - Código na Operadora / CNPJ / CPF

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31 - Nome do Contratado

32 - T.Log.

33-34-35 - Logradouro - Número - Complemento

36 - Município

37 - UF

38 - Cód. IBGE

39 - CEP

40 - Código CNES

40a - Código na Operadora / CNPJ / CPF do Exec. Complementar

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41 - Nome do Profissional Executante / Complementar

42 - Conselho Profissional

43 - Número no Conselho

44 - UF

45 - Código CBO S

45a - Grau de Participação

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DADOS DO ATENDIMENTO

46 - Tipo de Atendimento

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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

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

48 - Tipo de Saída

|___| 1 - Retorno 2 - Retorno SADT 3 - Referência 4 - Internação 5 - Alta 6 - Óbito

CONSULTA REFERÊNCIA

49 - Tipo de Doença

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A - Aguda C - Crônica

50 - Tempo de Doença

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

PROCEDIMENTOS E EXAMES REALIZADOS

51 - Data	52 - Hora Inicial	53 - Hora Final	54-Tab	55 - Código do Procedimento	57-Qde.	58-Via	59-Tec	60-% Red. / Acréscimo	61 - Valor Unitário - R$	62 - Valor Total - R$
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2-\|___\|___\|/\|___\|___\|/\|___\|___\|	\|___\|___\|:\|___\|___\| a	\|___\|___\|:\|___\|___\|	\|___\|___\|	\|___\|___\|___\|___\|___\|___\|___\|___\|___\|___\|	\|___\|___\|	\|___\|	\|___\|	\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|
3-\|___\|___\|/\|___\|___\|/\|___\|___\|	\|___\|___\|:\|___\|___\| a	\|___\|___\|:\|___\|___\|	\|___\|___\|	\|___\|___\|___\|___\|___\|___\|___\|___\|___\|___\|	\|___\|___\|	\|___\|	\|___\|	\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|
4-\|___\|___\|/\|___\|___\|/\|___\|___\|	\|___\|___\|:\|___\|___\| a	\|___\|___\|:\|___\|___\|	\|___\|___\|	\|___\|___\|___\|___\|___\|___\|___\|___\|___\|___\|	\|___\|___\|	\|___\|	\|___\|	\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|
5-\|___\|___\|/\|___\|___\|/\|___\|___\|	\|___\|___\|:\|___\|___\| a	\|___\|___\|:\|___\|___\|	\|___\|___\|	\|___\|___\|___\|___\|___\|___\|___\|___\|___\|___\|	\|___\|___\|	\|___\|	\|___\|	\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|	\|___\|___\|___\|___\|___\|,\|___\|___\|

63 - Data e Assinatura de Procedimentos em Série

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2 - |___|___|/|___|___|/|___|___| ______________ 4 - |___|___|/|___|___|/|___|___| ______________ 6 - |___|___|/|___|___|/_|___|___| _______________ 8 - |___|___|/|___|___|/|___|___| _____________ 10 - |___|___|/|___|___|/|___|___| _____________

64 - Observação

65 - Total Procedimentos - R$

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66 - Total Taxas e Aluguéis - R$

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67- Total Materiais - R$

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68 - Total Medicamentos - R$

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69 - Total Diárias - R$

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70 - Total Gases Medicinais - R$

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71 - Total Geral da Guia - R$

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86 - Data e Assinatura do Solicitante

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87 - Data e Assinatura do Responsável pela Autorização

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88 - Data e Assinatura do Beneficiário ou Responsável (*)

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89 - Data e Assinatura do Prestador Executante

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(*)Solicito auxílio para cobertura dos serviços especificados nesta guia, transferindo o seu pagamento ao prestador acima. Autorizo a cobrança da participação financeira a que estiver sujeito. Autorizo ao prestador anexar à esta guia cópias do prontuário médico e de quaisquer outros documentos relativos a este atendimento, para possibilitar a análise pelo setor médico da Hapvida.

OPM SOLICITADOS

72 - Tabela

73 - Código do OPM

74 - Descrição do OPM

75 - Qtde.

76 - Fabricante

77 - Valor Unitário - R$

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OPM UTILIZADOS

78 - Tabela

79 - Código do OPM

80 - Descrição do OPM

81 - Qtde.

82 - Código de Barras

83 - Valor Unitário - R$

84 - Valor Total - R$

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85 - Total OPM - R$

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ORIENTAÇÕES AO PRESTADOR:
1. O prazo de entrega de guias para cobrança é de até 90 (noventa) dias após a data do atendimento;
2. O prazo para solicitação de revisão de pagamento é de até 30 (trinta) dias após a data do pagamento.

Nº 13087690