Protocollo stomie - ASL di Brescia
Protocollo stomie - ASL di Brescia
Protocollo stomie - ASL di Brescia
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REGIONE LOMBARDIA <strong>ASL</strong> BRESCIA<br />
PROGRAMMA TERAPEUTICO PER L’EROGAZIONE DI FORNITURE PROTESICHE<br />
PERIODO DI VALIDITA’ DAL !____! !____! !____! AL !____! !____! !____!<br />
RICHIEDENTE: Cod. Reg.le Assistito !___!___!___!___!___!___!___!___! Sesso [ M ] [ F ]<br />
COGNOME _________________________ NOME ___________________ Data nascita ________________________<br />
Residenza Anagrafica<br />
Via ______________________________________ n. __________ Comune ___________________________________<br />
[1] VALUTAZIONE CLINICA E STRUMENTALE<br />
a) Sintesi dell’analisi funzionale b) Esiti esami strumentali<br />
______________________________________________ _______________________________________<br />
______________________________________________ _______________________________________<br />
______________________________________________ _______________________________________<br />
______________________________________________ _______________________________________<br />
______________________________________________ _______________________________________<br />
______________________________________________ _______________________________________<br />
[2] DIAGNOSI CIRCOSTANZIATA ____________________________________________________________________<br />
________________________________________________________________________________________________<br />
________________________________________________________________________________________________<br />
________________________________________________________________________________________________<br />
________________________________________________________________________________________________<br />
[3] CLASSIFICAZIONE DELLA FORNITURA<br />
[ ] PROTESI (Elenco 1)<br />
TIPO DI PRESIDIO NECESSARIO<br />
[ ] AUSILI TECNICI (Elenco 2)<br />
[ ] Monouso<br />
[ ] Riutilizzabili<br />
[ ] APPARECCHI (Elenco 3)<br />
28<br />
GRATUITA<br />
[ ]<br />
[ ]<br />
[ ]<br />
[ ]<br />
MODALITA’ DI FORNITURA<br />
A<br />
RIMBORSO<br />
[ ]<br />
[ ]<br />
[ ]<br />
TOTALMENTE<br />
A CARICO<br />
DELL’UTENTE<br />
[ ]<br />
[ ]<br />
[ ]<br />
SUPPORTO<br />
PRESCRIZIONE<br />
MOD. O3<br />
[ ]<br />
[ ]<br />
[ ]<br />
[ ]<br />
RICETTA<br />
COD. 7<br />
[ ]
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