ANEXA 39 C

- model ANEXA 1
LA DECIZIA DE NCHIRIERE A FOTOLIILOR RULANTE I A ECHIPAMENTELOR
PENTRU 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, urmnd ca pentru fiecare perioad lunar s predea aceluiai furnizor i celelalte
taloane.
PENTRU FOTOLII RULANTE
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|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
|
C3
|
C4
|
C5
|
C6
|
|_____|__________|________________|___________|__________|_________________________|
| 3 |
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|________________|
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|_____|__________|________________|___________|__________|_________________________|
| 2 |
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|________________|
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|_____|__________|________________|___________|__________|_________________________|
| 1 |
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|________________|
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|_____|__________|________________|___________|__________|_________________________|

PENTRU ECHIPAMENTE PENTRU OXIGENOTERAPIE

A. ACORDATE PENTRU 12 LUNI CONSECUTIVE
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|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
|
C3
|
C4
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C5
|
C6
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|_____|__________|________________|___________|__________|_________________________|
| 12 |
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|________________|
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|_____|__________|________________|___________|__________|_________________________|
| 11 |
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|________________|
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|_____|__________|________________|___________|__________|_________________________|

188

| 10 |
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|_____|_________|________________|___________|__________|_________________________|
| 9 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 8 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 7 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 6 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 5 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 4 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 3 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 2 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|
| 1 |
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|________________|
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|_____|_________|________________|___________|__________|_________________________|

B. ACORDATE PENTRU 90/91/92 DE ZILE

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|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
|
C3
|
C4
|
C5
|
C6
|
|_____|___________|________________|___________|__________|_________________________|
| 3 |
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|________________|
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|_____|___________|________________|___________|__________|_________________________|
| 2 |
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|________________|
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|_____|___________|________________|___________|__________|_________________________|
| 1 |
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|________________|
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|_____|___________|________________|___________|__________|_________________________|

189

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
|
C3
|
C4
|
C5
|
C6
|
|_____|___________|________________|___________|__________|_________________________|
| 3 |
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|________________|
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|_____|___________|________________|___________|__________|_________________________|
| 2 |
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|________________|
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|_____|___________|________________|___________|__________|_________________________|
| 1 |
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|________________|
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|_____|___________|________________|___________|__________|_________________________|

190