AF-guia_cobranca_odontologia.

pdf

12/9/13

2:37 PM

GUIA TRATAMENTO ODONTOLGICO

1 - Registro ANS

41913-3

Dados do Beneficirio
8 - Nmero da Carteira

3 - Data de Emisso da Guia

4 - Data da Autorizao

5-Senha

6 - Data Validade da Senha

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

9- Plano

7 - Numero Guia Principal

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

10- Empresa

11 - Data Validade da Carteira

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

12 - Nmero do Carto Nacional de Sade

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

14 - Telefone

13 - Nome

15 - Nome do titular do plano

(|___|___|)|___|___|___|___|-|___|___|___|___|
Dados do Contratado Responsvel pelo Tratamento
17 - Nmero no CRO

16 - Nome do Profissional Solicitante

20 - Cdigo na Operadora / CNPJ / CPF

21 - Nome do Contratado Executante

18 - UF

22 - Nmero no CRO

19 - Cdigo CBO S
23 - UF

24 - Cdigo CNES

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
25 - Nome do Profissional Executante

26 - Nmero no CRO

27 - UF

28 - Cdigo CBO S

Plano de Tratamento / Procedimentos Solicitados / Procedimentos Executados

29-Tabela 30 - Cdigo do Procedimento
31 - Descrio

32-Dente/ 33-Face 34-Qtd 35-Quantidade US

36-Valor R$
37-Franquia/Co-participao R$ 38-Aut 39-Data de Realizao
40-Assinatura
Regio
1-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________

2-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
3-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
4-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
5-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
6-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
7-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
8-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
9-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
10-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
11-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
12-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
13-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
14-|___|___| |___|___|___|___|___|___|___|___|___|___| __________________________________________ |_______| |________| |___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___| |___|___|/|___|___/|___|___| ____________________________
41 - Data Trmino do Tratamento

42 - Tipo de Atendimento

43 - Tipo de Faturamento

44 - Total Quantidade US

45 - Valor Total R$

46 - Total Franquia / Co-participao R$

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

|____| 1- Tratamento Odontolgico 2- Exame Radiolgico 3- Ortodontia 4- Urgncia/Emergncia 5- Auditoria |____| T - Total P - Parcial |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
Declaro, que aps ter sido devidamente esclarecido sobre os propsitos, riscos, custos e alternativas de tratamento, conforme acima apresentados, aceito e autorizo a execuo do tratamento, comprometendo-me a cumprir as orientaes do profissional assistente e arcar com os custos previstos em contrato. Declaro,
ainda, que o(s) procedimento(s) descrito(s) acima, e por mim assinado(s), foi/foram realizado(s) com meu consentimento e de forma satisfatria. Autorizo a Operadora a pagar em meu nome e por minha conta, ao profissional contratado que assina esse documento, os valores referentes ao tratamento realizado,
comprometendo-me a arcar com os custos conforme previsto em contrato.
47 - Observao
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
48 - Data, local e Assinatura do Cirurgio-Dentista Solicitante

49- Data, local e Assinatura do Cirurgio-Dentista

50 - Data, local e Assinatura do Beneficirio / Responsvel

51 - Data, local e Carimbo da Empresa

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

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

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

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