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REFERAT pentru aprobarea Ordinului ministrului sănătăţii publice şi ...

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ANEXA 13<br />

_____________________________________________________________________________<br />

| | | Nivel de prioritate | |<br />

| .......... | |_________________________| |<br />

| .......... | BILET DE TRIMITERE | URGENŢĂ | | |Curente | | |<br />

| .......... | Pentru analize medicale decontate |_________|_| |________|_| |<br />

| .......... | de C.A.S. |_________________________ |<br />

| (Cabinetul | | Asistent | ............ | |<br />

| medical) | | (Nume/ | ............ | |<br />

| | | cod) | ............ | |<br />

|____________|_____________________________________|__________|______________| |<br />

|______________________________________________________________________________|<br />

______________________________________________________________________________<br />

| __________________________________________________________________________ |<br />

| |DATE IDENTIFICARE PACIENT| |Nume| | |Prenume| | |<br />

| |_________________________| |____|_______________| |_______|_______________| |<br />

| _____________________________ ___ ___ ___ ______ ___ _ _ ____ _ _ |<br />

| |CNP| | | | | | | | | | | | | | |Sex| |F| ||M| | |Vârsta| |Ani| | ||Luni| | ||<br />

| |___|_|_|_|_|_|_|_|_|_|_|_|_|_| |___| |_|_||_|_| |______| |___|_|_||____|_|_||<br />

| __________________________________________________________________________ |<br />

| |Localitate| |Judeţ (Sector)| | |Str.| |Nr.| | | | |<br />

| |__________|_____________|______________|__|__|____|_____________|___|_|_|_| |<br />

| _________________________ ______________ _ ___________________ _ |<br />

| |Beneficiar: | |Pachet de bază| | | |Pachet facultativ*)| | | |<br />

| |_________________________| |______________| |_| |___________________| |_| |<br />

|______________________________________________________________________________|<br />

______________________________________________________________________________<br />

| ____________ ___________________________ ___________________________ |<br />

| | | | Nume | | | Prenume | | |<br />

| | DATE MEDIC | |______|____________________| |_________|_________________| |<br />

| | EXAMINATOR |__|__________________________________________________________| |<br />

| | | | Nr. cod parafă | | | | | Nr. contract | | | | |/|2|0| | | |<br />

| | | | | | | | | cu C.A.S. | | | | | | | | | | |<br />

| |____________| |________________|_|_|_|_|_______________|_|_|_|_|_|_|_|_|_| |<br />

| __________________________________________________________________________ |<br />

| |Cod diagnostic**)| . . . . | |Diagnostic prezumtiv| | |<br />

| |_________________|_________|_|____________________|_______________________| |<br />

| |__________________________________________________________________________| |<br />

| | Comentarii clinice: | | |<br />

| | | | |<br />

| | | | |<br />

| | | (Data, semnătura şi | |<br />

| | | parafa medicului | |<br />

| | | examinator) | |<br />

| |____________________________________________________|_____________________| |<br />

|______________________________________________________________________________|<br />

______________________________________________________________________________<br />

| ANALIZE RECOMANDATE: |<br />

| |<br />

| |<br />

| |<br />

| |<br />

| |<br />

| |<br />

|______________________________________________________________________________|<br />

*) Pachet de servicii medicale paraclinice <strong>pentru</strong> persoanele care se asigură facultativ <strong>pentru</strong> sănătate<br />

**) Cod diagnostic prezumtiv sau cunoscut<br />

Semnătura asiguratului<br />

<strong>pentru</strong> confirmarea efectuării investigaţiilor<br />

76

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