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ANEXO III |
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TRATAMENTO FORA DO DOMICÍLIO |
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SOLICITAÇÃO DE: ( ) REEMBOLSO DE GASTOS COM TRANSPORTE ( ) REEMBOLSO DE GASTOS COM HOSPEDAGEM ACOMPANHANTE: ( ) SIM ( ) NÃO
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1 – IDENTIFICAÇÃO NOME DO BENEFICIÁRIO: _____________________________________________________________________________ FILIAÇÃO: _____________________________________________________________________________ FUNÇÃO: _______________________ LOTAÇÃO: ___________________________________ MATRÍCULA: _____________________ TELEFONE: __________________________________ ENDEREÇO: _____________________________________________________________________________ NOME DO ACOMPANHANTE (se necessário): _____________________________________________________________________________ RG: ___________________________ TEL: __________________________________________ ENDEREÇO: _____________________________________________________________________________
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2 – HISTÓRIA DA DOENÇA ATUAL (preenchido pelo médico assistente): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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3 – EXAME FÍSICO: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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4 – DIAGNÓSTICO PROVÁVEL: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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5 – TRATAMENTO REALIZADO: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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6 – MOTIVO QUE IMPOSSIBILITA O TRATAMENTO NO DOMICÍLIO: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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7 – O PROCEDIMENTO E/OU TRATAMENTO INDICADO E SUAS VANTAGENS SOBRE O ASPECTO TÉCNICO: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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8 – EXAMES COMPLEMENTARES REALIZADOS (descrever os resultados): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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9 – O PROCEDIMENTO E/OU TRATAMENTO INDICADO IMPORTARÁ EM RECUPERAÇÃO TOTAL OU PARCIAL? (Justificar) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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10 – HÁ NECESSIDADE DE ENCAMINHAMENTO URGENTE? (Justificar) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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11 – HÁ NECESSIDADE DE ACOMPANHANTE? (Justificar) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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12 – PREVISÃO DO TEMPO NECESSÁRIO FORA DO DOMICÍLIO: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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PORTO VELHO, ________/________/________.
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________________________________________________ Médico assistente (Nome legível, CRM e assinatura)
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USO EXCLUSIVO DA GERÊNCIA MÉDICA DA REDE CONVENIADA |
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13 – CONCORDA COM AS EXPOSIÇÕES ACIMA? ( ) SIM ( ) NÃO JUSTIFICATIVA: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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13.1 – EM CASO DE CONCORDÂNCIA, INDICAR ONDE A REDE CREDENCIADA TEM MELHORES CONDIÇÕES DE ATENDER O BENEFICIÁRIO: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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PORTO VELHO, ________/________/________.
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__________________________________________________________________ (nome legível, CRM e assinatura da gerência médica da rede credenciada)
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PARECER DO SAMS/TRE–RO
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14 – É FAVORÁVEL À CONCESSÃO DO AUXÍLIO? ( ) SIM ( ) NÃO JUSTIFICATIVA: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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PORTO VELHO, ________/________/________.
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__________________________________________________ (nome legível, CRM e assinatura do médico do TRE/RO) |