REFERAT pentru aprobarea Ordinului ministrului sÄnÄtÄÅ£ii publice Åi ...
REFERAT pentru aprobarea Ordinului ministrului sÄnÄtÄÅ£ii publice Åi ...
REFERAT pentru aprobarea Ordinului ministrului sÄnÄtÄÅ£ii publice Åi ...
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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 />
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