resumo do manual de preenchimento das guias tiss · resumo do manual de preenchimento das guias...

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RESUMO DO MANUAL DE PREENCHIMENTO DAS GUIAS TISSAqui você encontra instruções para preencher corretamente os principais campos das Guias TISS.

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S Prezado(a) Referenciado(a),A mudança exigida pela ANS dos formulários de atendimento fez com que o MEDPLAN empregasse um grande esforço para se adequar à nova realidade.

O MEDPLAN está fazendo de tudo para tornar esta mudança a mais simples possível para a sua Rede de Referenciados, de forma a evitar atrasos e agilizar o pagamento dos serviços prestados.

O MEDPLAN entende a importância desse momento e, por isso, implementou uma série de alterações em sistemas e programas de informática. Mas a melhor maneira de passar rapidamente por esta fase de transição é trabalharmos juntos.

Esta cartilha é uma iniciativa no sentido de facilitar a compreensão sobre o que mudou. Você vai encontrar muitas orientações e dicas sobre como preencher os formulários de atendimento. Leia atentamente e tire todas as suas dúvidas.

Se precisar de mais informações visite o Portal TISS no endereço www.MEDPLAN.com.br ou entre em contato com o Medplan Teresina na rua Coelho Rodrigues, 1921/Centro - 64.000-080 - Teresina - PI - 86 3131-8888

SUMÁRIOGuia de Consulta, 05

Guia de Honorário Individual, 07

Guia SP/ SADT, 15

Guia Resumo de Internação, 21

Guia de Outras Despesas, 28

Estamos prontos para ajudar no que

for preciso. Juntos vamos alinhar por

completo a Troca de Informações em

Saúde Suplementar.O preenchimento correto dos formulários TISS é

fundamental para facilitar e agilizar o atendimento

aos nossos Referenciados. Preencha com calma e

tenha muita atenção nas orientações e dicas contidas

aqui. Fique atento ainda aos pontos destacados

para evitar problemas de preenchimento. Estamos

prontos para ajudar no que for preciso.

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NÚMERO DA CARTEIRA DO BENEFICIÁRIOO campo de cada guia correspondente ao “número da carteira” do beneficiário deverá conter 08 DÍGITOS (iniciando da esquerda para a direita).

ESCOLHA A GUIA CORRETA

• GUIA DE CONSULTA

• GUIA DE HONORÁRIO INDIVIDUAL

• GUIA SP/SADTPara a cobrança de evento ambulatorial que necessita de senha ambulatorial.Para a cobrança de evento de internação de prestador terceirizado, com senha de internação.Para a cobrança de consulta em horário de urgência.

• GUIA RESUMO DE INTERNAÇÃOPara a cobrança de despesas hospitalares, exames, terapias e honorários médicos cobrados pelo HOSPITAL, com senha de internação.

• GUIA DE OUTRAS DESPESASDeve estar sempre vinculada à Guia SP/SADT, ou Guia de Resumo de Internação.

IMPORTANTE

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SA Guia de Consulta deve ser utilizada exclusivamente na execução de consultas eletivas sem a realização de procedimento e constitui-se no documento-padrão para solicitação do pagamento.Este formulário não permite a cobrança de consulta em horário de urgência, que deverá ser, então, cobrada na guia SADT.

Campo 09Este campo deverá ser preenchido com o código do Referenciado.

CNPJ/CPF

GUIA DE CONSULTA

C o n f i a n ç a q u a n d o v o c ê m a i s p r e c i s a .

GUIA DE CONSULTA 2- Nº

32 - Data do Atendimento

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

7 - Nome

5 - Plano

9 - Código na Operadora / CNPJ / CPF

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

21 - Conselho Profissional 22 - Número no Conselho 23 - UF

35 - Tipo de Consulta

|___| 1 - Primeira 2 - Seguimento 3 - Pré-Natal

33-Codigo Tabela

|___|___|

36 - Tipo de Saída

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

38 - Data e Assinatura do Médico

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

39 - Data e Assinatura do Beneficiário ou Responsável

6 - Validade da Carteira

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

8 - Número do Cartão Nacional de Saúde

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

11 - Código CNES

24 - Código CBO S

12-T.L 13 - 14 - 15 - Logradouro - Número - Complemento 16 - Município 17 - UF 19 - CEP18 - Código IBGE

Dados do Atendimento / Procedimento Realizado

Hipóteses Diagnósticas

28 - CID Principal

|___|___|___|___|___|

25 - Tipo de Doença

|___| A - Aguda C - Crônica

26 - Tempo de Doença

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

27 - Indicação de Acidente

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

Dados do Contratado

Dados do Beneficiário

3 Data de Emissão da Guia-

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

37 - Observação

10- Nome do Contratado

1 - Registro ANS

20 - Nome do Profissional Executante

|___|___|___|___|___|___|___| - |___|___|___|

34 - Código Procedimento

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

|___|___|___|___|___|

29 - CID (2)

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

31 - CID (4)30 - CID (3)

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

4 - Número da Carteira (Matrícula)

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Campo 34Este campo deverá ser preenchido com o código específico de consulta.Cód. 10101012 – consulta em consultório (TUSS)

A ausência do código impede a valoração do preenchimento e o conseqüente pagamento.OBS.: Para as reconsultas, o campo 35 (TIPO DE CONSULTA) deverá ser preenchido com o código 2 (SEGUIMENTO) e, no campo 37, deverá constar a justificativa da reconsulta.

GUIA DE CONSULTA


GUIA DE CONSULTA 2- Nº

32 - Data do Atendimento

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

7 - Nome

5 - Plano


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


35 - Tipo de Consulta

|___| 1 - Primeira 2 - Seguimento 3 - Pré-Natal

33-Codigo Tabela

|___|___|

36 - Tipo de Saída

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

38 - Data e Assinatura do Médico

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

39 - Data e Assinatura do Beneficiário ou Responsável


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


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

11 - Código CNES

24 - Código CBO S

12-T.L 13 - 14 - 15 - Logradouro - Número - Complemento 16 - Município 17 - UF 19 - CEP18 - Código IBGE

Dados do Atendimento / Procedimento Realizado


28 - CID Principal

|___|___|___|___|___|

25 - Tipo de Doença


26 - Tempo de Doença

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



Dados do Contratado


3 Data de Emissão da Guia-

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

37 - Observação

10- Nome do Contratado

1 - Registro ANS

20 - Nome do Profissional Executante

|___|___|___|___|___|___|___| - |___|___|___|

34 - Código Procedimento

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

|___|___|___|___|___|

29 - CID (2)

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

31 - CID (4)30 - CID (3)

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


A Guia de Honorário Individual é um formuláriopadrão a ser utilizado para a apresentação do faturamento de honorários profissionais prestados em serviço de internação, caso estes sejam pagos diretamente ao profissional.Cada participante do procedimento deverá preencher 01 (uma) guia de Honorário Individual.Horário de urgência: deverão ser informadas a hora inicial e final dos procedimentos realizados.Este campo deverá ser preenchido apenas com a senha liberada para INTERNAÇÃO.

GUIA DE HONORÁRIO INDIVIDUAL

Campo 03Este campo deverá ser preenchido apenas com a senha liberada para INTERNAÇÃO

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

2- Nº


37-Data/Hora e Assinatura do Prestador

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

38-Data/Horae Assinatura do Beneficiário ou Responsável

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

4 - Data de Emissão da Guia

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

1 - Registro ANS 3 - Nº Guia de Solicitação / Senha

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

8 - Nome

6 - Plano 7 - Validade da Carteira

Dados do Contratado (onde foi executado o procedimento)

Dados do Contratado Executante

18 - Nome do Profissional Executante 19 - Conselho Profissional 20 - Número no Conselho 21 - UF 22 - Número no CPF17-Grau Part.

|___|___|

Procedimentos Realizados

36 - Observação

35 - Total Geral Honorários R$

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


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

11 - Nome do Contratado 12 - Código CNES

15- Código CNES13 - Código na Operadora / CNPJ / CPF

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

14 - Nome do Contratado Executante 16 - Tipo da Acomodação Autorizada

|___|___|

23-Data 24-Hora Inicial 25-Hora Final 26-Tabela 27-Código do Procedimento 28-Descrição 29-Qtde. 30-Via 31-Tec. 32-% Red. / Acresc. 33-Valor Unitário - R$ 34-Valor Total - R$

1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


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Campo 13 Este campo deverá ser preenchido com o código do Referenciado no MEDPLAN.

CNPJ/CPF


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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


Campo 17Este campo deverá ser preenchido com o grau de participação do profissional da equipe médica, de acordo com a tabela de domínio (disponível no Portal TISS no site do MEDPLAN).A ausência do grau de participação impede a valoração do procedimento e, conseqüentemente, o pagamento.


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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


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Campo 23 Este campo deverá ser preenchido com a data da REALIZAÇÃO de CADA procedimento.


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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


Campo 27Refere-se à codificação de cada procedimento, conforme TABELA TUSS DO MEDPLAN.


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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


Campo 29Se o campo referido for preenchido com mais de um atendimento (ex.: visitas, plantões, avaliações parenterais), será necessário informar o período correspondente ao campo 36.


Campo 34Neste campo deverá ser informado o valor correspondente ao procedimento realizado, considerando a quantidade executada do procedimento e valores conforme tabela divulgada no Portal TISS e plano do segurado.


16 |

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17 |

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

2- Nº



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


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


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


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

8 - Nome





|___|___|


36 - Observação


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


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



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


|___|___|


1- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

2- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

5- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

6- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

7- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

8- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

9- |___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

10-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ___________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|



|___|___|___|___|___|___|___| - |___|___|___|


Campo 36Preenchimento necessário, com a justificativa médica dos procedimentos cobrados.

GUIA DE HONORÁRIO INDIVIDUALA Guia de Serviços Profissionais / Serviço Auxiliar Diagnóstico e Terapia deve ser utilizada no atendimento a diversos tipos de eventos: • Remoção; • Pequena cirurgia; • Terapias (fisioterapias, psicoterapias, fonoaudiologia, terapia ocupacional, acupuntura); • Consulta (quando associada a procedimentos / exames / materiais e medicamentos, consulta de referência e consulta realizada em horário de urgência); • Exames; • Atendimento domiciliar (não utilizado pela seguradora); • SADT internado, quando da cobrança de serviços terceirizados; • Quimioterapia, radioterapia ou terapia renal substitutiva (TRS).

GUIA SP / SADT

Campo 30 Este campo deverá ser preenchido com o código do Referenciado no MEDPLAN.

CNPJ/CPF

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

2- Nº

5-Senha

22 - Caráter da Solicitação

|___| E- U-Urgência/EmergênciaEletiva

23 - CID 10

|___|___|___|___|___|

3 - Nº Guia Principal

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

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

1 - Registro ANS

11 - Nome9- Plano 10 - Validade da Carteira

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


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



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

17 - Conselho Profissional 18 - Número no Conselho 19 - UF 20 - Código CBO S

14 - Nome do Contratado

Dados do Contratado Solicitante

15 - Código CNES

16 - Nome do Profissional Solicitante

Dados da Solicitação / Procedimentos e Exames Solicitados

6 - Data Validade da Senha

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


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

4 - Data da Autorização

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

21 - Data/Hora da Solicitação

|___|___| / |___|___| / |___|___| |___|___|:|___|___|

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

40-Código CNES32-T.L. 33-34-35-Logradouro - Número - Complemento 36 - Município 37 - UF 39 - CEP38 - Cód. IBGE

46-Tipo Atendimento01 - 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


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



42 - Conselho Profissional 43 - Número no Conselho 44 - UF 45 - Código CBO S41 - Nome do Profissional Executante/Complementar

Dados do Atendimento



49 -Tipo de Doença

|___| A-Aguda C -Crônica

50 -Tempo de Doença

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

Procedimentos e Exames realizados

48- Tipo de Saída

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

40- Código na Operadora / CPF do exec. complementar

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

45 - Grau de Participação

|___|___|

88-Data e Assinatura do Beneficiário ou Responsável

89- Data e Assinatura do Prestador Executante86 - Data e Assinatura do Solicitante 87 - Data e Assinatura do Responsável pela Autorização

65 - Total Procedimentos R$

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

66 - Total Taxas e Aluguéis R$

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

67- Total Materiais R$

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

68 - Total Medicamentos R$

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

69 - Total Diárias R$

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

70 - Total Gases Medicinais R$

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

71 - Total Geral da Guia R$

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

63-Data e Assinatura de Procedimentos em Série

1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________ 9 - |___|___|/|___|___|/|___|___| ______________________

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

64 - Observação

25-Tabela 26- Código do Procedimento 27 - Descrição 28.Qt.Solic. 29-Qt.Autoriz.

1 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|

2 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____| 3 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|


11 - Nome

Consulta Referência

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 |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

|___|___|___|___|___|___|___| - |___|___|___|


18 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

19 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

Campo 45AEste campo deverá ser preenchido com o grau de participação do profissional na equipe médica, de acordo com a tabela de domínio, apenas nos casos de procedimentos cirúrgicos, atendimento AMBULATORIAL, ou INTERNADO quando realizado por prestador terceirizado, com cobrança de materiais e medicamentos. OBS.: Os materiais e medicamentos deverão ser discriminados na guia de outras despesas.

GUIA SP / SADT

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

2- Nº

5-Senha



23 - CID 10

|___|___|___|___|___|


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


1 - Registro ANS


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


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



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




15 - Código CNES




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


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


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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|






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







49 -Tipo de Doença





48- Tipo de Saída



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


|___|___|




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


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


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


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


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


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


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


1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________ 9 - |___|___|/|___|___|/|___|___| ______________________

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

64 - Observação


1 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|

2 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____| 3 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|


11 - Nome



2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

|___|___|___|___|___|___|___| - |___|___|___|


Campo 46Neste campo deverá ser preenchido o código do tipo de atendimento, conforme abaixo:

Remoção = 01Pequena Cirurgia = 02Terapia = 03Consulta = 04Exame = 05

GUIA SP / SADT

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

2- Nº

5-Senha



23 - CID 10

|___|___|___|___|___|


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


1 - Registro ANS


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


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



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




15 - Código CNES




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


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


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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|






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







49 -Tipo de Doença





48- Tipo de Saída



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


|___|___|




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


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


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


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


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


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


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


1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________ 9 - |___|___|/|___|___|/|___|___| ______________________

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

64 - Observação


1 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|

2 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____| 3 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|


11 - Nome



2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

|___|___|___|___|___|___|___| - |___|___|___|


Atendimento Domiciliar = 06SADT Internado = 07Quimioterapia = 08Radioterapia = 09TRS Terapia Renal Substitutiva = 10

OBS.: para a cobrança de pequenos atendimentos, ou de consulta e exames, deverá ser utilizado o tipo de atendimento - 02.

20 |

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MO

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MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

21 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

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

2- Nº

5-Senha



23 - CID 10

|___|___|___|___|___|


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


1 - Registro ANS


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


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



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




15 - Código CNES




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


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


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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|






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







49 -Tipo de Doença





48- Tipo de Saída



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


|___|___|




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


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


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


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


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


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


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


1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________ 9 - |___|___|/|___|___|/|___|___| ______________________

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

64 - Observação


1 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|

2 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____| 3 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|


11 - Nome



2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

|___|___|___|___|___|___|___| - |___|___|___|


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

2- Nº

5-Senha



23 - CID 10

|___|___|___|___|___|


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


1 - Registro ANS


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


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



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




15 - Código CNES




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


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


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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|






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







49 -Tipo de Doença





48- Tipo de Saída



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


|___|___|




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


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


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


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


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


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


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


1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________ 9 - |___|___|/|___|___|/|___|___| ______________________

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

64 - Observação


1 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|

2 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____| 3 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|


11 - Nome



2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

|___|___|___|___|___|___|___| - |___|___|___|


Campo 51É importante e obrigatório o preenchimento da data do evento.

GUIA SP / SADT

Campo 55É importante e obrigatório o preenchimento do código do procedimento realizado, conforme tabela TUSS. A ausência de codificação impede a valoração do procedimento e, conseqüentemente, o pagamento.

GUIA SP / SADT

22 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

23 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

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

2- Nº

5-Senha



23 - CID 10

|___|___|___|___|___|


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


1 - Registro ANS


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


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



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




15 - Código CNES




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


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


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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|






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







49 -Tipo de Doença





48- Tipo de Saída



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


|___|___|




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


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


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


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


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


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


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


1 - |___|___|/|___|___|/|___|___| _________________________ 3 - |___|___|/|___|___|/|___|___| _________________________ 5 - |___|___|/|___|___|/|___|___| ______________________ 7 - |___|___|/|___|___|/|___|___| ______________________ 9 - |___|___|/|___|___|/|___|___| ______________________

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

64 - Observação


1 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|

2 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____| 3 - |____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________________________________________________________________________________________________ |____|____| |____|____|


11 - Nome



2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _____________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |____|____|____|____|____|,|____|____| |____|____|____|____|____|,|____|____|

|___|___|___|___|___|___|___| - |___|___|___|


Campos 66, 67 e 68É OBRIGATÓRIO o preenchimento destes campos, quando da utilização de taxas, materiais, medicamentos e gazes sendo informados os valores totais de cada grupo. A discriminação item a item deverá ser efetuada na guia de outras despesas. OBS.: A ausência de preenchimento desses campos impedirá a liberação do pagamento correspondente.

GUIA SP / SADTA Guia Resumo de Internação é o formulário-padrão a ser utilizado para o faturamento da internação.A cobrança realizada pelo hospital pode incluir:• Honorários médicos, quando cobrados pelo hospital;• Exames e terapias, quando em regime de internaçãoe não realizados por terceiros;• Diárias, taxas, materiais, medicamentos e OPM.

GUIA RESUMO DE INTERNAÇÃO

Campo 13Este campo deverá ser preenchido com o código do Referenciado no MEDPLAN.

CNPJ/CPF - NÃO USAR

2- Nº

GUIA DE RESUMO DE INTERNAÇÃO

28 - Tipo Internação

|___| 1-Clínica 2-Cirurgica 3-Obstétrica 4-Pediátrica 5-Psiquiátrica

37-CID 10 Principal

|___|___|___|___|___|

41 - Indicador de Acidente

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

38 - CID 10 (2)

|___|___|___|___|___|

40 - CID 10 (4)

|___|___|___|___|___|

39 - CID 10 (3)

|___|___|___|___|___|

42 - Motivo Saída

|___|___|

30 - Internação Obstétrica - (selecione mais de um se necessário com "X")

34 - Qtde. Nasc. Vivos a Termo

|___|___|

35 - Qtde. Nasc. Mortos

|___|___|

36 - Qtde. Nasc. Vivos Prematuro

|___|___|

31 - Se óbito em mulher

|___| 1- Grávida 2 - até 42 dias após término gestação 3 - de 43 dias a 12 meses após término gestação

32 - Se óbito neonatal

|___| - Qtde. óbito neonatal precoce |___| - Qtde. óbito neonatal tardio

43 - CID 10 Óbito

|___|___|___|___|___|

44 - Nº Declaração do Óbito

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

3 - Nº Guia de Solicitação

1 - Registro ANS 7 - Data de Emissão da Guia


15- Código CNES

17-18-19 - Logradouro - Número - Complemento 20 - Município 21 - UF 23- CEP22 - Cód. IBGE

13 - Código na Operadora / CNPJ

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

|___|-Em gestação |___|-Aborto |___|-Transtorno materno relacionado a gravidez |___|-Complic. Puerpério |___|-Atend. ao RN na sala de parto |___|-Complicação Neonatal |___|-Bx. Peso <2,5 Kg. |___|-Parto Cesáreo |___|-Parto Normal



11 - Nome

9 - Plano

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



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

29 - Regime de Internação

|___| 1 -Hospitalar 2 -Hospital-dia 3 -Domiciliar

33 - Nº Decl. Nasc. Vivos

5-Senha 6 - Data Validade da Senha

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


25 -Tipo Acomodação Autorizada 26 - Data/Hora da Internação

|___|___| / |___|___| / |___|___| |___|___|:|___|___|

27 - Data/Hora da Saída Internação24 - Caráter da Internação

|___| E - Eletiva U - Urgência/Emergência |___|___|


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

73 - Tipo Faturamento R$

|___|___| / |___|___| / |___|___| |___|___|:|___|___|

|___| - Total |___| - Parcial


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


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

77 - Total Materiais R$

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


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

79- Total Gases Medicinais R$

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

80 - Total Geral R$

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

83-Data e Assinatura do(s) Auditor(es) da Operadorae Assinatura do Contratado82-Data


1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

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

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

16-T.L.

Dados da Internação

Dados da Saída da Internação

Procedimentos e Exames Realizados

Identificação da Equipe

57-Seq.Ref 58-Gr.Part. 59-Código na Operadora/CPF 60-Nome do Profissional 61-Conselho Prof. 62-Número Conselho 63-UF 64-CPF

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________


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

|___|___|___|___|___|___|___| - |___|___|___|


24 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

25 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

Campos 26 e 27 Para casos com cobranças de contas parciais, esses campos deverão ser preenchidos com o período da fatura cobrada.

GUIA RESUMO DE INTERNAÇÃO2- Nº




37-CID 10 Principal

|___|___|___|___|___|



38 - CID 10 (2)

|___|___|___|___|___|

40 - CID 10 (4)

|___|___|___|___|___|

39 - CID 10 (3)

|___|___|___|___|___|

42 - Motivo Saída

|___|___|



|___|___|


|___|___|


|___|___|





43 - CID 10 Óbito

|___|___|___|___|___|


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




15- Código CNES



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




11 - Nome

9 - Plano

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



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





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



|___|___| / |___|___| / |___|___| |___|___|:|___|___|




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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|



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


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


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


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


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

80 - Total Geral R$

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



1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

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

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

16-T.L.






|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________


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

|___|___|___|___|___|___|___| - |___|___|___|


2- Nº




37-CID 10 Principal

|___|___|___|___|___|



38 - CID 10 (2)

|___|___|___|___|___|

40 - CID 10 (4)

|___|___|___|___|___|

39 - CID 10 (3)

|___|___|___|___|___|

42 - Motivo Saída

|___|___|



|___|___|


|___|___|


|___|___|





43 - CID 10 Óbito

|___|___|___|___|___|


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




15- Código CNES



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




11 - Nome

9 - Plano

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



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





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



|___|___| / |___|___| / |___|___| |___|___|:|___|___|




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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|



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


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


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


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


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

80 - Total Geral R$

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



1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

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

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

16-T.L.






|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________


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

|___|___|___|___|___|___|___| - |___|___|___|


Campo 49 É importante e obrigatório o preenchimento do código do procedimento realizado, se COBRADO pelo hospital. A ausência do código impede a valoração do procedimento e o conseqüente pagamento.


26 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

27 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

2- Nº




37-CID 10 Principal

|___|___|___|___|___|



38 - CID 10 (2)

|___|___|___|___|___|

40 - CID 10 (4)

|___|___|___|___|___|

39 - CID 10 (3)

|___|___|___|___|___|

42 - Motivo Saída

|___|___|



|___|___|


|___|___|


|___|___|





43 - CID 10 Óbito

|___|___|___|___|___|


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




15- Código CNES



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




11 - Nome

9 - Plano

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



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





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



|___|___| / |___|___| / |___|___| |___|___|:|___|___|




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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|



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


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


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


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


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

80 - Total Geral R$

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



1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

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

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

16-T.L.






|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________


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

|___|___|___|___|___|___|___| - |___|___|___|


Campo 58Este campo deverá ser preenchido com o grau de participação do profissional na equipe médica, de acordo com a tabela de domínio, apenas quando houver cobrança de HONORÁRIO MÉDICO pelo HOSPITAL.


Campos 65, 66 e 6765 – Tabela – Deverá sempre ser utilizada a codificação 95.67 – Deverá ser transcrita a descrição completa do material com a marca do fabricante.

GUIA RESUMO DE INTERNAÇÃOProrrogações

|____|____|/|____|____|/|____|____| ___________________________________ ____________________________________________ 58-Tipo Acomod 59-Acomodação 60- Qtde. Autorizada

|____|____| ______________________________________________________ |____|____|

61-Tabela 62 - Código do Procedimento 63 - Descrição 64-Qtde. Solic 65-Qtde. Aut

|__ _| ___| |_ __|__ _|__ _|_ __|_ __|_ __|_ __|_ __|_ __| ___| ________________________________________________________________________________________ |__ _| ___| |_ __|_ __| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

|____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________ |____|____| |____|____|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

55- Data 56-Senha 57-Responsável pela Autorização

66-Tabela 67-Código do OPM 68-Descrição OPM 69-Qtde. 70-Fabricante 71 - Valor Unitário R$


|____|____| ______________________________________________________ |____|____|


|__ _| ___| |_ __|__ _|__ _|_ __|_ __|_ __|_ __|_ __|_ __| ___| ________________________________________________________________________________________ |__ _| ___| |_ __|_ __| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

|____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________ |____|____| |____|____|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|




|____|____| ______________________________________________________ |____|____|


|__ _| ___| |_ __|__ _|__ _|_ __|_ __|_ __|_ __|_ __|_ __| ___| ________________________________________________________________________________________ |__ _| ___| |_ __|_ __| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

|____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________ |____|____| |____|____|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|



28 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

29 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

Prorrogações


|____|____| ______________________________________________________ |____|____|


|__ _| ___| |_ __|__ _|__ _|_ __|_ __|_ __|_ __|_ __|_ __| ___| ________________________________________________________________________________________ |__ _| ___| |_ __|_ __| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

|____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________ |____|____| |____|____|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|




|____|____| ______________________________________________________ |____|____|


|__ _| ___| |_ __|__ _|__ _|_ __|_ __|_ __|_ __|_ __|_ __| ___| ________________________________________________________________________________________ |__ _| ___| |_ __|_ __| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

|____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________ |____|____| |____|____|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|




|____|____| ______________________________________________________ |____|____|


|__ _| ___| |_ __|__ _|__ _|_ __|_ __|_ __|_ __|_ __|_ __| ___| ________________________________________________________________________________________ |__ _| ___| |_ __|_ __| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

|____|____| |____|____|____|____|____|____|____|____|____|____| ________________________________________________________________________________________ |____|____| |____|____|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|

|___|___| |___|___|___|___|___|___|___|___|___|___| ____________________________________ |___|___| ____________________________ |___|___|___|___|___|___|,|___|___|



Campo 71Refere-se ao total geral apenas do OPM (este valor deverá ser somado ao campo 80 da guia).


Campo 73 Deverá ser preenchido com o código “T” somente se a data final da fatura (campo 27) corresponder à alta hospitalar do segurado.

GUIA RESUMO DE INTERNAÇÃO2- Nº




37-CID 10 Principal

|___|___|___|___|___|



38 - CID 10 (2)

|___|___|___|___|___|

40 - CID 10 (4)

|___|___|___|___|___|

39 - CID 10 (3)

|___|___|___|___|___|

42 - Motivo Saída

|___|___|



|___|___|


|___|___|


|___|___|





43 - CID 10 Óbito

|___|___|___|___|___|


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




15- Código CNES



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




11 - Nome

9 - Plano

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



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





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



|___|___| / |___|___| / |___|___| |___|___|:|___|___|




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


|___|___| / |___|___| / |___|___| |___|___|:|___|___|



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


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


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


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


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

80 - Total Geral R$

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



1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___|

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

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

16-T.L.






|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________

|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _____________________________________________________________________ ______________________________ ____________________________ _______ ________________________________


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

|___|___|___|___|___|___|___| - |___|___|___|


30 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

31 |

RESU

MO

DO

MAN

UAL

DE

PREE

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HIM

ENTO

DAS

GUI

AS T

ISS

2- Nº


GUIA DE SOLICITAÇÃO

DE INTERNAÇÃO

22 - Caráter da Internação

E - Eletiva U - Urgência/Emergência

26 - Indicação Clínica

________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________

23-Tipo de Internação

1 - Clínica 2 - Cirúrgica 3 - Obstétrica 4 - Pediátrica 5 - Psiquiátrica


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

1 - Registro ANS

10 - Nome


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



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


14 - Código CNES

19 - Código CBO S



Dados do Contratado Solicitado / Dados da Internação

20- Código na Operadora / CNPJ

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

21 - Nome do Prestador

25 - Qtde. Diarias Solicitadas

|___|___|___|


|___| 2 3 1 - Hospitalar - Hospital-dia - Domiciliar

4 - Senha 5 - Data Validade da Senha

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


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


30-CID 10 Principal

|___|___|___|___|___|

27-Tipo Doença


28-Tempo de Doença Referida pelo Paciente

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


|___| 0 - Acidente ou doença relacionada ao Trabalho 1 - Trânsito 2 - Outros

31 - CID 10 (2) 33 - CID 10 (4)32 - CID 10 (3)


-|_ _| ___| |_ __|_ __|_ __| ___|_ __| ___| ___|_ __|_ __|_ __| _______________________________ __________________________________________________________ |_ __|_ __|__ _ _ _ _ _ _ _ _ _ _ _ __ |____|____| _ _

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

47 - Tipo da Acomodação Autorizada

|___|___|

45 - Data Provável da Admissão Hospitalar

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

46 - Qtde. Diarias Autorizadas

|___|___|___|


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

49 - Nome do Prestador Autorizado 50 - Código CNES

OPM Solicitados


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

52-Data e Assinatura do Médico Solicitante

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

54-Data e Assinatura do Responsável pela Autorização

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

Procedimentos Solicitados


|___| |___|

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

1

2

3

4

5

51 - Observação

Dados da Autorização

39-Tabela 40-Código do OPM 41-Descrição OPM 42-Qtde. 43-Fabricante 44-Valor Unitário R$

1-|_ __|_ __| |_ __|_ __|__ _|__ _|_ __|__ _|_ __| ___|_ __|_ __| ____________________ ___________________________ |__ _|_ __| _______ __________ ___ |___ |_ __|__ _|__ _|__ _|_ __|,|___|____|

2-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

3-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

4-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

5-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

_ _ _ _ _ _ _ _ _ _ _ _ _____ _ _ ____ ____ _ _ _ _ _ _


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

|___|___|___|___|___|___|___| - |___|___|___|


Deve estar sempre vinculada à Guia SP / SADT, ou à Guia Resumo de Internação.A Guia de Outras Despesas deve ser utilizada para cobranças de diárias, taxas, materiais, medicamentos, gases medicinais e aluguéis, tanto nos atendimentos AMBULATORIAIS quanto nos INTERNADOS.A ausência de codificação do item impede a valoração e o conseqüente pagamento.OBS.: Materiais e medicamentos deverão ser codificados conforme tabela SIMPRO ou BRASINDICE - TISS.

Campo 03Este campo deverá ser preenchido com o código do Referenciado no MEDPLAN.

CNPJ/CPF - NÃO USAR

GUIA DE OUTRAS DESPESAS 2- Nº


GUIA DE SOLICITAÇÃO

DE INTERNAÇÃO

22 - Caráter da Internação

E - Eletiva U - Urgência/Emergência

26 - Indicação Clínica

________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________

23-Tipo de Internação

1 - Clínica 2 - Cirúrgica 3 - Obstétrica 4 - Pediátrica 5 - Psiquiátrica


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

1 - Registro ANS

10 - Nome


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



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


14 - Código CNES

19 - Código CBO S



Dados do Contratado Solicitado / Dados da Internação

20- Código na Operadora / CNPJ

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

21 - Nome do Prestador

25 - Qtde. Diarias Solicitadas

|___|___|___|


|___| 2 3 1 - Hospitalar - Hospital-dia - Domiciliar

4 - Senha 5 - Data Validade da Senha

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


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


30-CID 10 Principal

|___|___|___|___|___|

27-Tipo Doença


28-Tempo de Doença Referida pelo Paciente

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


|___| 0 - Acidente ou doença relacionada ao Trabalho 1 - Trânsito 2 - Outros

31 - CID 10 (2) 33 - CID 10 (4)32 - CID 10 (3)


-|_ _| ___| |_ __|_ __|_ __| ___|_ __| ___| ___|_ __|_ __|_ __| _______________________________ __________________________________________________________ |_ __|_ __|__ _ _ _ _ _ _ _ _ _ _ _ __ |____|____| _ _

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

- |____|____| |____|____|____|____|____|____|____|____|____|____| ___________________________________________________________________________________________ |____|____| |____|____|

47 - Tipo da Acomodação Autorizada

|___|___|

45 - Data Provável da Admissão Hospitalar

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

46 - Qtde. Diarias Autorizadas

|___|___|___|


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

49 - Nome do Prestador Autorizado 50 - Código CNES

OPM Solicitados


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

52-Data e Assinatura do Médico Solicitante

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

54-Data e Assinatura do Responsável pela Autorização

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

Procedimentos Solicitados


|___| |___|

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

1

2

3

4

5

51 - Observação

Dados da Autorização

39-Tabela 40-Código do OPM 41-Descrição OPM 42-Qtde. 43-Fabricante 44-Valor Unitário R$

1-|_ __|_ __| |_ __|_ __|__ _|__ _|_ __|__ _|_ __| ___|_ __|_ __| ____________________ ___________________________ |__ _|_ __| _______ __________ ___ |___ |_ __|__ _|__ _|__ _|_ __|,|___|____|

2-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

3-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

4-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

5-|____|____| |____|____|____|____|____|____|____|____|____|____| ____________________________________________________ |____|____| ____________________________ |____|____|____|____|____|____|,|___|____|

_ _ _ _ _ _ _ _ _ _ _ _ _____ _ _ ____ ____ _ _ _ _ _ _


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

|___|___|___|___|___|___|___| - |___|___|___|


Campo 12A cobrança de cada item poderá corresponder à quantidade total do período faturado.Ex.: diária - cód. 80011179 - quantidade 05 Soro glicosado - cód. (BRASINDICE - TISS) quantidade 30.

GUIA DE OUTRAS DESPESAS

32 |

RESU

MO

DO

MAN

UAL

DE

PREE

NC

HIM

ENTO

DAS

GUI

AS T

ISS

resumo do manual de preenchimento das guias tiss · resumo do manual de preenchimento das guias...

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