7/24/2019 ANEXA 39 C

1/3

ANEXA 39 C - model -

ANEXA 1

LA DECIZIA DE NCHIRIERE A FOTOLIILOR RULANTE I A ECHIPAMENTELORPENTRU OXIGENOTERAPIE I VENTILAIE NONINVAZIV!NR" """"""#""""""""""""""""

- Prezenta anex se pred mpreun cu decizia;

- CAS va tampila rubrica aferent fiecrei perioade lunare pentru care este valabil decizia;

- Se ncepe completarea taloanelor de jos n sus; - Asiguratul pred furnizorului decizia mpreun cu talonul corespunztor perioadei lunare

aferente urm!nd ca pentru fiecare perioad lunar s predea aceluiai furnizor i celelalte

taloane"

PENTRU FOTOLII RULANTE__________________________________________________________________________________|Nr. |Perioada | Nume i prenume| Act | Decizie | Data i semntura de ||talon|zi/lun/an| CNP/cod unic de| identitate| nr./data | primire a dispozitivului|| | | asigurare | | | medical ||_____|__________|________________|___________|__________|_________________________|| C1 | C2 | C | C! | C" | C# ||_____|__________|________________|___________|__________|_________________________|| | | | | | || | |________________| | | || | | | | | ||_____|__________|________________|___________|__________|_________________________|| 2 | | | | | || | |________________| | | || | | | | | ||_____|__________|________________|___________|__________|_________________________|| 1 | | | | | || | |________________| | | || | | | | | ||_____|__________|________________|___________|__________|_________________________|

PENTRU ECHIPAMENTE PENTRU OXIGENOTERAPIE

A" ACORDATE PENTRU 1$ LUNI CON%ECUTIVE__________________________________________________________________________________|Nr. | Perioada | Nume i prenume| Act | Decizie | Data i semntura de ||talon|zi/lun/an| CNP/cod unic de| identitate| nr./data | primire a dispozitivului|| | | asigurare | | | medical |

|_____|__________|________________|___________|__________|_________________________|| C1 | C2 | C | C! | C" | C# ||_____|__________|________________|___________|__________|_________________________|| 12 | | | | | || | |________________| | | || | | | | | ||_____|__________|________________|___________|__________|_________________________|| 11 | | | | | || | |________________| | | || | | | | | ||_____|__________|________________|___________|__________|_________________________|

#$$

7/24/2019 ANEXA 39 C

2/3

| 1$ | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| % | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| & | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| ' | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| # | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| " | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| ! | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| 2 | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|| 1 | | | | | || | |________________| | | || | | | | | ||_____|_________|________________|___________|__________|_________________________|

&" AC%&'A() P)*(&+ ,.,#.,/ ') 012)

___________________________________________________________________________________|Nr. | Perioada | Nume i prenume| Act | Decizie | Data i semntura de ||talon| zi/lun/an| CNP/cod unic de| identitate| nr./data | primire a dispozitivului|| | | asigurare | | | medical ||_____|___________|________________|___________|__________|_________________________|| C1 | C2 | C | C! | C" | C# ||_____|___________|________________|___________|__________|_________________________|| | | | | | |

| | |________________| | | || | | | | | ||_____|___________|________________|___________|__________|_________________________|| 2 | | | | | || | |________________| | | || | | | | | ||_____|___________|________________|___________|__________|_________________________|| 1 | | | | | || | |________________| | | || | | | | | ||_____|___________|________________|___________|__________|_________________________|

#$,

7/24/2019 ANEXA 39 C

3/3

PENTRU ECHIPAMENTE DE VENTILAIE NONINVAZIV!

___________________________________________________________________________________|Nr. | Perioada | Nume i prenume| Act | Decizie | Data i semntura de ||talon| zi/lun/an| CNP/cod unic de| identitate| nr./data | primire a dispozitivului|| | | asigurare | | | medical ||_____|___________|________________|___________|__________|_________________________|

| C1 | C2 | C | C! | C" | C# ||_____|___________|________________|___________|__________|_________________________|| | | | | | || | |________________| | | || | | | | | ||_____|___________|________________|___________|__________|_________________________|| 2 | | | | | || | |________________| | | || | | | | | ||_____|___________|________________|___________|__________|_________________________|| 1 | | | | | || | |________________| | | || | | | | | ||_____|___________|________________|___________|__________|_________________________|

#,