Informācija par medicīniski pamatotu papildinājumu atļautajai plānotajai aprūpei

DA008 - Informācija par medicīniski pamatotu papildinājumu atļautajai plānotajai aprūpei
Regulas (EK) Nr. 883/2004 20. un 36. pants, Regulas (EK) Nr. 987/2009 26. panta 5. punkts, 33. pants

SED API version: 0.16.2 build 2
Model version: 4.2.0

Persona * [ SC ]

Personas dati * [ CC ]

Uzvārds(-i) *

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Vārds(-i) *

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Dzimšanas datums *

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Dzimums *

[ ENUM ] {{metaSection.sex.$$error}} {{metaSection.sex.$$warning}}

Dzimtais uzvārds

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Dzimtais vārds

[ BDT ] {{metaSection.forenameAtBirth.$$error}} {{metaSection.forenameAtBirth.$$warning}}

Personas identifikācijas numurs katrā iestādē [ CC ]

Personas identifikācijas numurs(-i) * [ CC ]

Valsts *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Personas identifikācijas numurs (PIN) *

[ BDT ] {{metaSection.personalIdentificationNumber.$$error}} {{metaSection.personalIdentificationNumber.$$warning}}

Nozare

[ ENUM ] {{metaSection.sector.$$error}} {{metaSection.sector.$$warning}}

Iestāde [ CC ]

Iestādes identifikācijas numurs *

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Iestādes nosaukums *

[ CDT ] {{metaSection.institutionName.$$error}} {{metaSection.institutionName.$$warning}}

Personas identifikācijas numurs(-i)

Ja nevienai iestādei nav iesniegts PIN, norādiet to [ CC ]

Dzimšanas vieta [ CC ]

Pilsēta *

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Reģions

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Valsts *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Tēva dzimtais uzvārds

[ BDT ] {{metaSection.fatherFamilyNameAtBirth.$$error}} {{metaSection.fatherFamilyNameAtBirth.$$warning}}

Tēva vārds

[ BDT ] {{metaSection.forenameFather.$$error}} {{metaSection.forenameFather.$$warning}}

Mātes dzimtais uzvārds

[ BDT ] {{metaSection.motherFamilyNameAtBirth.$$error}} {{metaSection.motherFamilyNameAtBirth.$$warning}}

Mātes vārds

[ BDT ] {{metaSection.forenameMother.$$error}} {{metaSection.forenameMother.$$warning}}

Papildu informācija par personu [ SC ]

Valstspiederība

[ ENUM ] {{metaSection.nationality.$$error}} {{metaSection.nationality.$$warning}}

Iepriekšējais(-ie) uzvārds(-i)

[ BDT ] {{metaSection.previousFamilyName.$$error}} {{metaSection.previousFamilyName.$$warning}}

Iepriekšējais(-ie) uzvārds(-i)

[ BDT ] {{metaSection.previousForename.$$error}} {{metaSection.previousForename.$$warning}}

Personas adreses [ SC ]

Personas adrese [ SC ]

Adrese [ CC ]

Iela

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

Ēkas nosaukums

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

Pilsēta *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

Pasta indekss

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

Reģions

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Valsts *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Adreses veids

[ ENUM ] {{metaSection.typeAddress.$$error}} {{metaSection.typeAddress.$$warning}}

Personas adrese

Šis SED ir saistīts ar * [ SC ]

SED veids *

[ ENUM ] {{metaSection.typeOfSED.$$error}} {{metaSection.typeOfSED.$$warning}}

Datums *

[ BDT ] {{metaSection.date.$$error}} {{metaSection.date.$$warning}}

Kods

[ CDT ] {{metaSection.code.$$error}} {{metaSection.code.$$warning}}

Kodēšanas sistēma

[ CDT ] {{metaSection.codingSystem.$$error}} {{metaSection.codingSystem.$$warning}}

Apraksts

[ CDT ] {{metaSection.description.$$error}} {{metaSection.description.$$warning}}

Personas statuss

[ ENUM ] {{metaSection.statusPerson.$$error}} {{metaSection.statusPerson.$$warning}}

Aizpildīt šo, ja “Personas statuss” = “Cits” : [ SC ]

Personas statuss (ja “Cits”)

[ CDT ] {{metaSection.statusPersonIfOther.$$error}} {{metaSection.statusPersonIfOther.$$warning}}

Darba devējs [ CC ]

Nosaukums *

[ CDT ] {{metaSection.name.$$error}} {{metaSection.name.$$warning}}

Identifikācijas numuri [ CC ]

Identifikācijas numurs [ CC ]

Numurs *

[ CDT ] {{metaSection.number.$$error}} {{metaSection.number.$$warning}}

Veids *

[ ENUM ] {{metaSection.type.$$error}} {{metaSection.type.$$warning}}

Identifikācijas numurs

Adrese [ CC ]

Iela

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

Ēkas nosaukums

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

Pilsēta *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

Pasta indekss

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

Reģions

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Valsts *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Medicīniski pamatots papildinājums, lai atļautu plānotu ārstēšanu * [ SED ]

Plānotas ārstēšanas sākotnējās atļaujas datums *

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Papildu ārstēšana * [ SC ]

Apraksts *

[ CDT ] {{metaSection.description.$$error}} {{metaSection.description.$$warning}}

Aprūpes pakalpojumu sniedzēja pieprasījuma datums *

[ BDT ] {{metaSection.datePersonRequest.$$error}} {{metaSection.datePersonRequest.$$warning}}

Nodrošinātājs * [ SC ]

Nosaukums *

[ CDT ] {{metaSection.name.$$error}} {{metaSection.name.$$warning}}

Adrese * [ CC ]

Iela

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

Ēkas nosaukums

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

Pilsēta *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

Pasta indekss

[ CDT ] {{metaSection.postalCode.$$error}} {{metaSection.postalCode.$$warning}}

Reģions

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

Valsts *

[ ENUM ] {{metaSection.country.$$error}} {{metaSection.country.$$warning}}

Ārstēšanas periods * [ CC ]

Sākuma datums *

[ BDT ] {{metaSection.startDate.$$error}} {{metaSection.startDate.$$warning}}

Beigu datums *

[ BDT ] {{metaSection.endDate.$$error}} {{metaSection.endDate.$$warning}}

izsniegt ārsta ziņojumu * [ SC ]

Pielikumā medicīniskā izziņa *

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Papildu informācija [ SC ]

Papildu informācija

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DA008 - Informācija par medicīniski pamatotu papildinājumu atļautajai plānotajai aprūpei Regulas (EK) Nr. 883/2004 20. un 36. pants, Regulas (EK) Nr. 987/2009 26. panta 5. punkts, 33. pants

DA008 - Informācija par medicīniski pamatotu papildinājumu atļautajai plānotajai aprūpei
Regulas (EK) Nr. 883/2004 20. un 36. pants, Regulas (EK) Nr. 987/2009 26. panta 5. punkts, 33. pants