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Transcript of Guia de Consulta - 3.0 - cooperclin.com.brcooperclin.com.br/portal/images/guias/Guia de Consulta -...
![Page 1: Guia de Consulta - 3.0 - cooperclin.com.brcooperclin.com.br/portal/images/guias/Guia de Consulta - Sambemat.pdf · GUIA DE CONSULTA 18 - Data do Atendimento |___|___| / |___|___|](https://reader034.fdocument.pub/reader034/viewer/2022050807/5be6df7609d3f26f698bb034/html5/thumbnails/1.jpg)
GUIA DE CONSULTA
18 - Data do Atendimento
|___|___| / |___|___| / |___|___|___|___|
7 – Nome
9- Código na Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
13 - ConselhoProfissional
|___|___|
14 - Número no Conselho
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
15 - UF
|___|___|
19 - Tipo de Consulta
|___|
20 - Tabela
|___|___|
25 - Assinatura do Beneficiário ou Responsável
5 - Validade da Carteira
|___|___| / |___|___| / |___|___|___|___|
16 - Código CBO
|__|__|__|__|__|__|
Dados do Atendimento / Procedimento Realizado
17 - Indicação de Acidente (acidente ou doença relacionada)
|___|
Dados do Contratado
Dados do Beneficiário
10 - Nome do Contratado
1 - Registro ANS
|___|___|___|___|___|___|
12 - Nome do Profissional Executante
4 - Número da Carteira
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
21 - Código do Procedimento
|___|___|___|___|___|___|___|___|___|___|
22 - Valor do Procedimento
|___|___|___|___|___|___|,|___|___|
8 - Cartão Nacional de Saúde
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
23 - Observação / Justificativa____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
11 - Código CNES
|___|___|___|___|___|___|___|
6 – Atendimento a RN (Sim ou Não)
|___|
2- Nº Guia no Prestador
24 - Assinatura do Profissional Executante
3 - Número da Guia Atribuído pela Operadora
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
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