Gerador de APAC

Formulário PDF editável

IDENTIFICAÇÃO DO ESTABELECIMENTO DE SAÚDE (SOLICITANTE)

1 - Nome do Estabelecimento de Saúde Solicitante

2 - CNES

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IDENTIFICAÇÃO DO PACIENTE

3 - Nome do Paciente

4 - Nº do Prontuário

5 - Cartão Nacional de Saúde (CNS)

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6 - Data de Nascimento

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7 - Sexo

Masc.Fem.

8 - Nome da Mãe ou Responsável

9 - Telefone de Contato

DDD

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Nº DO TELEFONE

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10 - Endereço (Rua, Nº, Bairro)

11 - Município de Residência

12 - Cód. IBGE Município

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13 - UF

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14 - CEP

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PROCEDIMENTO SOLICITADO

15 - Código do Procedimento Principal

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16 - Nome do Procedimento Principal

17 - QTDE

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PROCEDIMENTO(S) SECUNDÁRIO(S)

18 - Código do Procedimento Secundário

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19 - Nome do Procedimento Secundário

20 - QTDE

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21 - Código do Procedimento Secundário

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22 - Nome do Procedimento Secundário

23 - QTDE

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24 - Código do Procedimento Secundário

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25 - Nome do Procedimento Secundário

26 - QTDE

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27 - Código do Procedimento Secundário

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28 - Nome do Procedimento Secundário

29 - QTDE

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30 - Código do Procedimento Secundário

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31 - Nome do Procedimento Secundário

32 - QTDE

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JUSTIFICATIVA DO(S) PROCEDIMENTO(S) SOLICITADO(S)

33 - Descrição do Diagnóstico

34 - CID10 Principal

35 - CID10 Secundário

36 - CID10 Causas Associadas

37 - Observações

SOLICITAÇÃO

38 - Nome do Profissional Solicitante

39 - Data da Solicitação

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42 - Assinatura e Carimbo (Nº Registro do Conselho)

40 - Documento

CNSCPF

41 - Nº Documento (CNS/CPF) do Profissional Solicitante

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AUTORIZAÇÃO

43 - Nome do Profissional Autorizador

44 - Cód. Órgão Emissor

49 - Nº da Autorização (APAC)

45 - Documento

CNSCPF

46 - Nº Documento (CNS/CPF) do Profissional Autorizador

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47 - Data da Autorização

48 - Assinatura e Carimbo (Nº do Registro do Conselho)

50 - Período de Validade da APAC

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a

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IDENTIFICAÇÃO DO ESTABELECIMENTO DE SAÚDE (EXECUTANTE)

51 - Nome Fantasia do Estabelecimento de Saúde Executante

52 - CNES

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