ORDIN   Nr. 1186/898 din 17 decembrie 2003

privind modificarea si completarea Ordinului ministrului sanatatii si al presedintelui Casei Nationale de Asigurari de Sanatate nr. 849/297/2003 privind aprobarea formularelor de prescriptie medicala cu regim special pentru medicamente cu si fara contributie personala, precum si cele cu timbru sec si a normelor metodologice privind utilizarea si modul de completare a formularelor de prescriptie medicala cu regim special pentru medicamente cu si fara contributie personala, precum si cele cu timbru sec

ACT EMIS DE: MINISTERUL SANATATII - Nr. 1.186

              CASA NATIONALA DE ASIGURARI DE SANATATE - Nr. 898
ACT PUBLICAT IN: MONITORUL OFICIAL  NR. 938 din 24 decembrie 2003

    In temeiul prevederilor:
    - Ordonantei de urgenta a Guvernului nr. 150/2002 privind organizarea si functionarea sistemului de asigurari sociale de sanatate, cu modificarile si completarile ulterioare;
    - Ordonantei de urgenta a Guvernului nr. 152/1999 privind medicamentele de uz uman, aprobata si modificata prin Legea nr. 336/2002, cu modificarile si completarile ulterioare;
    - Legii nr. 73/1969 privind regimul produselor si al substantelor stupefiante;
    - Hotararii Guvernului nr. 743/2003 privind organizarea si functionarea Ministerului Sanatatii,
    avand in vedere Referatul comun al Ministerului Sanatatii si al Casei Nationale de Asigurari de Sanatate nr. 6.614/2.783 din 17 decembrie 2003,

    ministrul sanatatii si presedintele Casei Nationale de Asigurari de Sanatate emit urmatorul ordin:

    Art. 1
    Anexa nr. 1 la Ordinul ministrului sanatatii si al presedintelui Casei Nationale de Asigurari de Sanatate nr. 849/297/2003 privind aprobarea formularelor de prescriptie medicala cu regim special pentru medicamente cu si fara contributie personala, precum si cele cu timbru sec si a normelor metodologice privind utilizarea si modul de completare a formularelor de prescriptie medicala cu regim special pentru medicamente cu si fara contributie personala, precum si cele cu timbru sec, publicat in Monitorul Oficial al Romaniei, Partea I, nr. 665 din 19 septembrie 2003, se inlocuieste cu anexa care face parte integranta din prezentul ordin.
    Art. 2
    Prezentul ordin se publica in Monitorul Oficial al Romaniei, Partea I.

                            Ministrul sanatatii,
                              Ovidiu Branzan

            Presedintele Casei Nationale de Asigurari de Sanatate,
                              Cristian Celea

    ANEXA 1*)

    *) Anexa este reprodusa in facsimil.

 ______________________________________________________________________________
| REGIM SPECIAL                              Serie _______ Numar ____________  |
|          _                               _             _                _    |
|      MF |_|    Ambulatoriu Specialitate |_|    Spital |_|    Ambulanta |_|   |
|                                                                              |
| 1. Cabinet medical/spital                                                    |
|    Cod fiscal                                                                |
|    Sediu (localitate, str., nr.)                                   L.S.      |
|    Judetul                                                                   |
|    Casa de asigurari/Nr. Contract                                            |
| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ |
|               Gratuita                       :Compensata:    Legi speciale   |
| Copii       Boli cronice      Altele         :          :                    |
|  _                                           :    _     :  _                 |
| |_| sugar   Cod boala ______  Cod program    :   |_|    : |_| handicapati    |
|  _                            national _____ :          :  _                 |
| |_| copil                     _ _ _ _ _ _ _ _:          : |_| veterani       |
|  _                            _              :          :  _                 |
| |_| elev                     |_| gravida     :          : |_| revolutionari  |
|  _                            _              :          :  _                 |
| |_| ucenic                   |_| lauza       :          : |_| alte gratuitati|
|  _                            _ _ _ _ _ _ _ _:          :                    |
| |_| student                   _              :          :                    |
|                              |_| protejati   :          :                    |
|                                  social      :          :                    |
| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _:_ _ _ _ _ : _ _ _ _ _ _ _ _ _ _|
|                _          _             _              _                     |
| 2. Asigurat:  |_| copil  |_| salariat  |_| pensionar  |_| plata   La CAS ....|
|                                                           directa            |
| Nume                                         Str.                  Nr.       |
| Prenume                                      Bl.         Sc.       Ap.       |
| Varsta         Carnet asigurat               Loc.            Judet           |
|      _ _ _ _ _ _ _ _ _ _ _ _ _                                               |
| CNP |_|_|_|_|_|_|_|_|_|_|_|_|_|                                              |
| Nr. Foii de observatie/Nr. Din Registrul de Consultatii                      |
|                                                      ____ _______ ____       |
| 3. Diagnostic                                       | ac.| subac.| cr.|      |
|                                                     |____|_______|____|      |
|                                                                              |
|  __________________________________________________________________________  |
| |4. Rp.                                  | DS          | Cant. |  Parafa   | |
| |________________________________________|_____________|_______|___________| |
| |   1  |                                 |             |       |             |
| |______|_________________________________|_____________|_______|             |
| |   2  |                                 |             |       |             |
| |______|_________________________________|_____________|_______|             |
| |   3  |                                 |             |       |             |
| |______|_________________________________|_____________|_______|             |
| |      |                                 |             |       |             |
| |______|_________________________________|_____________|_______|             |
|         Data prescriere:                        Semnatura medic:             |
|  Taxare:                                                                     |
|  __________________________________________________________________________  |
| |Rp.| Medicament | Cant. Elib. | Pret       | P. ref.  | Val.   |Compensare| |
| |   |            |             | amanunt/ut | (min)/ut | Amanunt|CAS       | |
| |___|____________|_____________|____________|__________|________|__________| |
| | 1 |            | _ _ _ _ _ _ | _ _ _ _ _ _|_ _ _ _ _ | _ _ _ _|_ _ _ _ _ | |
| |___|____________|_____________|____________|__________|________|__________| |
| | 2 |            | _ _ _ _ _ _ | _ _ _ _ _ _|_ _ _ _ _ | _ _ _ _|_ _ _ _ _ | |
| |___|____________|_____________|____________|__________|________|__________| |
| | 3 |            | _ _ _ _ _ _ | _ _ _ _ _ _|_ _ _ _ _ | _ _ _ _|_ _ _ _ _ | |
| |___|____________|_____________|____________|__________|________|__________| |
| |   |            |             |            |          |        |          | |
| |___|____________|_____________|____________|__________|________|__________| |
| Contributie asigurat:                                    Total:              |
|                                                                              |
| Data eliberarii:                                         Bon fiscal nr.      |
|                                                 _             _              |
| 5. Am primit medicamentele mai sus mentionate  |_| Asigurat  |_| Imputernicit|
| Nume                                    Str.                     Nr.         |
| Prenume                                 Loc.             Judet               |
| B.I.(C.I.) seria            Nr.                                              |
|      _ _ _ _ _ _ _ _ _ _ _ _ _                                               |
| CNP |_|_|_|_|_|_|_|_|_|_|_|_|_|                                              |
| Semnatura                                                                    |
|                                                         L.S. Farmacie        |
| Semnatura persoanei care elibereaza                                          |
|______________________________________________________________________________|