Screening
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Anexa nr. 3 la normele metodologice Centrul de informare și consiliere a femeilor Reprezentantul legal al furnizorului Privind măsurile de prevenire a cancerului de de servicii medicale col uterin și de mobilizare a populaţiei eligibile ...................................................................................... pentru testarea Babeș Papanicolau reprezentat prin Medic de familie ..................................................................................... ...................................................................................... Adresa: ....................................................................... Număr contract încheiat cu CAS: ............................... BORDEROU CENTRALIZATOR pentru luna............... anul ..... _________________________________________________________________________________ |Nr. |CNP al femeii cu | Data | Seria |Tarif/ |Total sumă | |crt. |fomularul FS1 completat | eliberării |formularului|caz testat |de decontat| | |în integralitate |formularului| |Babeș | (lei) | | | | FS1 | |Papanicolau| | | | | | | (lei) | | |______|________________________|____________|____________|___________|___________| | C0 | C1 | C2 | C3 | C4 | C5 | |______|________________________|____________|____________|___________|___________| | 1 | | | | 15 | 15 | |______|________________________|____________|____________|___________|___________| | 2 | | | | | | |______|________________________|____________|____________|___________|___________| | 3 | | | | | | |______|________________________|____________|____________|___________|___________| | 4 | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| | | | | | | | |______|________________________|____________|____________|___________|___________| |TOTAL:| x | x | x | x | | |______|________________________|____________|____________|___________|___________|
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Transcript of Screening
MINISTERUL SNTII CASA NAIOANAL DE ASIGURRI DE SNTATE
Anexa nr. 3 la normele metodologice Centrul de informare i consiliere a femeilor
Reprezentantul legal al furnizorului
Privind msurile de prevenire a cancerului de de servicii medicale
col uterin i de mobilizare a populaiei eligibile ...................................................................................... pentru testarea Babe Papanicolau reprezentat prin Medic de familie
..................................................................................... ...................................................................................... Adresa: ....................................................................... Numr contract ncheiat cu CAS: ...............................
BORDEROU CENTRALIZATORpentru luna............... anul .....
_________________________________________________________________________________ |Nr. |CNP al femeii cu | Data | Seria |Tarif/ |Total sum |
|crt. |fomularul FS1 completat | eliberrii |formularului|caz testat |de decontat|
| |n integralitate |formularului| |Babe | (lei) |
| | | FS1 | |Papanicolau| | | | | | | (lei) | |
|______|________________________|____________|____________|___________|___________|
| C0 | C1 | C2 | C3 | C4 | C5 |
|______|________________________|____________|____________|___________|___________|
| 1 | | | | 15 | 15 |
|______|________________________|____________|____________|___________|___________|
| 2 | | | | | |
|______|________________________|____________|____________|___________|___________|
| 3 | | | | | |
|______|________________________|____________|____________|___________|___________|
| 4 | | | | | |
|______|________________________|____________|____________|___________|___________|
| | | | | | |
|______|________________________|____________|____________|___________|___________|
| | | | | | |
|______|________________________|____________|____________|___________|___________|
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|______|________________________|____________|____________|___________|___________|
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|______|________________________|____________|____________|___________|___________|
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|______|________________________|____________|____________|___________|___________|
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|______|________________________|____________|____________|___________|___________|
| | | | | | |
|______|________________________|____________|____________|___________|___________|
|TOTAL:| x | x | x | x | |
|______|________________________|____________|____________|___________|___________| Rspundem de realitatea i exactitatea datelor.
Reprezentant legal,.................................................(semntura i tampila)
