APPENDIX NO 1 to the Methodological Norms
Sanitary Facility Registration No …………………. of the date of ………………
ENDORSED
National Health Insurance House
Chief Physician
(date, signature, seal)
MEDICAL REPORT
for the patient applying for obtaining the prior approval for the reimbursement of the
equivalent value of the cross-border medical assistance
1. Medical doctor ………….. (name and first name) ……………………………………..,
specialized in ……………………………., from the ward ……………………. of the
Clinic/County Hospital ………………………………………………………………....
2. Patient …………………. (name and first name)……………………………………….
with the PIN …………………………, having the domicile in ………………………..
3. Patient is under the monitoring, by the clinic, starting with the date of ………………..
4. Patient was admitted in hospital based on the last Medical Record no ………………..
5. Patient has the diagnostic of ...........................................................................................
……………………………………………………………………………………………
……………………………………………………………………………………………
6. Description of short history of the affections and treatments applied: ………………….
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
7. Type of prescribed medical assistance*):
umor articular endoprosthetic reconstruction
Segmental spinal implant
Coronary bypass with/without invasive cardiac examinations
Birth
In the above mentioned context, I consider that the patient may benefit of cross-border
medical assistance, because:
a) No hospital in Romania can provide such services within a medically
reasonable term, taking into account the current health condition and
potential evolution of the disease of the assured person, because (explanation
and argumentation of the reasons based on which the requested medical
service may not be provided in Romania within a medically reasonable
term):
...................................................................................................................
…………………………………………………………………………..
…………………………………………………………………………….
…………………………………………………………………………….
b)
The movement of the applicant assured person does not damage his/her
health condition or the receipt of medical treatment (explanation and
argumentation): …………………………………………………………..
……………………………………………………………………………
To this Medical Report, the following written medical instruments**) supporting the type of
prescribed medical assistance shall be attached: ………………………………...
…………………………………………………………………………………………….
…………………………………………………………………………………………….
…………………………………………………………………………………………….
8. Drawn up by medical doctor:
Name: ……………………………
Signature and seal: ……………………………
9. Signed for compliance by HEAD OF WARD:
Name: ……………………………
Signature and seal: ……………………………
10. Approved by HOSPITAL MANAGER
Name: ……………………………
Signature and hospital round seal: ……………
*)
Thick the type of prescribed medical assistance
The written medical instruments shall be dated, signed and sealed.
**)
NOTE: Not filling-in all the headings of the report shall invalidate this report.
COMMENTS (the rejection of approval by the Head of the competent Health Insurance
House shall be hereby reasoned):