Çàðåãèñòðèðîâàíî â Ìèíþñòå ÐÔ 15 íîÿáðÿ 2006 ã. N 8478

 

ÌÈÍÈÑÒÅÐÑÒÂÎ ÇÄÐÀÂÎÎÕÐÀÍÅÍÈß È ÑÎÖÈÀËÜÍÎÃÎ ÐÀÇÂÈÒÈß

ÐÎÑÑÈÉÑÊÎÉ ÔÅÄÅÐÀÖÈÈ

 

ÏÐÈÊÀÇ

îò 25 îêòÿáðÿ 2006 ã. N 730

 

Î âíåñåíèè èçìåíåíèé

â ïðèêàç Ìèíèñòåðñòâà çäðàâîîõðàíåíèÿ

è ñîöèàëüíîãî ðàçâèòèÿ Ðîññèéñêîé Ôåäåðàöèè

îò 28 íîÿáðÿ 2005 ã. N 701 "Î ðîäîâîì ñåðòèôèêàòå"

 

 öåëÿõ ðåàëèçàöèè â 2007 ãîäó ôóíêöèé ïî îïëàòå ãîñóäàðñòâåííûì è ìóíèöèïàëüíûì ó÷ðåæäåíèÿì çäðàâîîõðàíåíèÿ (à ïðè èõ îòñóòñòâèè ìåäèöèíñêèì îðãàíèçàöèÿì, â êîòîðûõ â óñòàíîâëåííîì çàêîíîäàòåëüñòâîì Ðîññèéñêîé Ôåäåðàöèè ïîðÿäêå ðàçìåùåí ìóíèöèïàëüíûé çàêàç) óñëóã â ÷àñòè ìåäèöèíñêîé ïîìîùè, îêàçàííîé æåíùèíàì â ïåðèîä áåðåìåííîñòè è ðîäîâ, à òàêæå â ÷àñòè äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà â òå÷åíèå ïåðâîãî ãîäà æèçíè, ïðèêàçûâàþ:

1. Âíåñòè èçìåíåíèÿ â Ïðèêàç Ìèíèñòåðñòâà çäðàâîîõðàíåíèÿ è ñîöèàëüíîãî ðàçâèòèÿ Ðîññèéñêîé Ôåäåðàöèè îò 28 íîÿáðÿ 2005 ã. N 701 "Î ðîäîâîì ñåðòèôèêàòå" (çàðåãèñòðèðîâàí â Ìèíèñòåðñòâå þñòèöèè Ðîññèéñêîé Ôåäåðàöèè 30 äåêàáðÿ 2005 ã. N 7337) ñîãëàñíî ïðèëîæåíèþ.

2. Íàñòîÿùèé Ïðèêàç âñòóïàåò â ñèëó ñ 1 ÿíâàðÿ 2007 ãîäà.

 

Ìèíèñòð

Ì.Þ.ÇÓÐÀÁÎÂ

 

 

 

 

 

Ïðèëîæåíèå

ê Ïðèêàçó

Ìèíèñòåðñòâà çäðàâîîõðàíåíèÿ

è ñîöèàëüíîãî ðàçâèòèÿ

Ðîññèéñêîé Ôåäåðàöèè

îò 25 îêòÿáðÿ 2006 ã. N 730

 

ÈÇÌÅÍÅÍÈß,

ÂÍÎÑÈÌÛÅ Â ÏÐÈÊÀÇ ÌÈÍÈÑÒÅÐÑÒÂÀ ÇÄÐÀÂÎÎÕÐÀÍÅÍÈß

È ÑÎÖÈÀËÜÍÎÃÎ ÐÀÇÂÈÒÈß ÐÎÑÑÈÉÑÊÎÉ ÔÅÄÅÐÀÖÈÈ

ÎÒ 28 ÍÎßÁÐß 2005 Ã. N 701 "Î ÐÎÄÎÂÎÌ ÑÅÐÒÈÔÈÊÀÒÅ"

 

1. Â Ïðèêàçå:

â ïðåàìáóëå ñëîâà "â 2006 ãîäó" èñêëþ÷èòü, ïîñëå ñëîâ "ó÷ðåæäåíèÿìè çäðàâîîõðàíåíèÿ" äîïîëíèòü ñëîâàìè "à òàêæå â ÷àñòè äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà â òå÷åíèå ïåðâîãî ãîäà æèçíè";

ïóíêò 2 èñêëþ÷èòü.

2. Èçëîæèòü ïðèëîæåíèå N 1 ê Ïðèêàçó "Ôîðìà ðîäîâîãî ñåðòèôèêàòà" â íîâîé ðåäàêöèè ñîãëàñíî Ïðèëîæåíèþ ê íàñòîÿùèì èçìåíåíèÿì.

3. Â ïðèëîæåíèè N 2 ê Ïðèêàçó "Èíñòðóêöèÿ ïî çàïîëíåíèþ ðîäîâîãî ñåðòèôèêàòà":

ïóíêò 1 ïîñëå ñëîâ "àêóøåðñòâî è ãèíåêîëîãèÿ" äîïîëíèòü ñëîâàìè ", à òàêæå îñóùåñòâëÿþùèìè äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà â òå÷åíèå ïåðâîãî ãîäà æèçíè, èìåþùèìè ëèöåíçèþ íà ìåäèöèíñêóþ äåÿòåëüíîñòü â ÷àñòè îñóùåñòâëåíèÿ ðàáîò è óñëóã ïî ñïåöèàëüíîñòè "ïåäèàòðèÿ";

â ïóíêòå 2:

â àáçàöå ïåðâîì ñëîâî "÷åòûðåõ" çàìåíèòü ñëîâîì "øåñòè";

äîïîëíèòü àáçàöàìè øåñòûì è ñåäüìûì, èçëîæèâ èõ â ñëåäóþùåé ðåäàêöèè:

"ïÿòàÿ ÷àñòü - òàëîí N 3-2 ðîäîâîãî ñåðòèôèêàòà, ïðåäíàçíà÷åííûé äëÿ îïëàòû ó÷ðåæäåíèÿì çäðàâîîõðàíåíèÿ óñëóã çà âòîðûå øåñòü ìåñÿöåâ äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà;

øåñòàÿ ÷àñòü - òàëîí N 3-1 ðîäîâîãî ñåðòèôèêàòà, ïðåäíàçíà÷åííûé äëÿ îïëàòû ó÷ðåæäåíèÿì çäðàâîîõðàíåíèÿ óñëóã çà ïåðâûå øåñòü ìåñÿöåâ äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà.";

â ïóíêòå 6:

â àáçàöå ÷åòâåðòîì ñëîâà "íà ìîìåíò ïîñòàíîâêè æåíùèíû íà ó÷åò äëÿ íàáëþäåíèÿ â ñâÿçè ñ áåðåìåííîñòüþ è ïîëíîå ÷èñëî íåäåëü" èñêëþ÷èòü;

â àáçàöå äåâÿòîì ñëîâà "Äàòà ðîæäåíèÿ" çàìåíèòü ñëîâàìè "Äàòà ðîæäåíèÿ æåíùèíû";

â àáçàöå äâåíàäöàòîì ñëîâà "(òðåóãîëüíàÿ ïå÷àòü, ïðåäóñìîòðåííàÿ äëÿ ëèñòêîâ íåòðóäîñïîñîáíîñòè)" èñêëþ÷èòü, ïîñëå ñëîâ "æåíñêîé êîíñóëüòàöèè" äîáàâèòü çíàê ñíîñêè è èçëîæèòü åå â ñëåäóþùåé ðåäàêöèè:

"<*> Çäåñü è äàëåå - ïðè îòñóòñòâèè ó æåíñêîé êîíñóëüòàöèè (ðîäèëüíîãî äîìà) ïå÷àòè òàëîí ðîäîâîãî ñåðòèôèêàòà çàâåðÿåòñÿ ïå÷àòüþ ñîîòâåòñòâóþùåãî ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, â ñîñòàâ êîòîðîãî âõîäèò æåíñêàÿ êîíñóëüòàöèÿ (ðîäèëüíûé äîì).";

â ïóíêòå 7:

â àáçàöå ñåäüìîì ñëîâà "Äàòà ðîæäåíèÿ" çàìåíèòü ñëîâàìè "Äàòà ðîæäåíèÿ æåíùèíû";

â àáçàöå äåñÿòîì ñëîâà "(òðåóãîëüíàÿ ïå÷àòü, ïðåäóñìîòðåííàÿ äëÿ ëèñòêîâ íåòðóäîñïîñîáíîñòè)" èñêëþ÷èòü;

â ïóíêòå 8:

àáçàö ÷åòâåðòûé äîïîëíèòü ñëîâàìè "â ñëó÷àå ñìåðòè ìàòåðè èëè ðåáåíêà";

â àáçàöå ïÿòîì ñëîâà "(òðåóãîëüíàÿ ïå÷àòü, ïðåäóñìîòðåííàÿ äëÿ ëèñòêîâ íåòðóäîñïîñîáíîñòè, â ñëó÷àå åñëè æåíùèíà ðîæàëà íå ïî ìåñòó æèòåëüñòâà - ïðîñòàâëÿåòñÿ êðóãëàÿ ïå÷àòü)" èñêëþ÷èòü;

â ïóíêòå 9.1:

â àáçàöå ïåðâîì ñëîâà "æåíñêîé êîíñóëüòàöèè" çàìåíèòü ñëîâàìè "ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò";

â àáçàöå âòîðîì ñëîâî "áåðåìåííîé" èñêëþ÷èòü;

â àáçàöå ïÿòîì ñëîâà "æåíñêîé êîíñóëüòàöèè, âûäàâøåé ðîäîâûé ñåðòèôèêàò, èëè ñòàâèòñÿ åå øòàìï" çàìåíèòü ñëîâàìè "ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò, èëè ñòàâèòñÿ åãî øòàìï";

â ïóíêòå 9.2:

â àáçàöå ïåðâîì öèôðû "6 - 9" çàìåíèòü öèôðàìè "6 - 10";

äîïîëíèòü àáçàöåì øåñòûì, èçëîæèâ åãî â ñëåäóþùåé ðåäàêöèè:

"â ï. 10 "×èñëî äåòåé ó æåíùèíû, âêëþ÷àÿ ðîæäåííûõ ðàíåå" óêàçûâàåòñÿ îáùåå ÷èñëî äåòåé, èìåþùèõñÿ ó æåíùèíû, âêëþ÷àÿ ðîæäåííûõ åþ ðàíåå.";

àáçàö øåñòîé ñ÷èòàòü àáçàöåì ñåäüìûì;

â àáçàöå ñåäüìîì ñëîâà "(òðåóãîëüíàÿ ïå÷àòü, ïðåäóñìîòðåííàÿ äëÿ ëèñòêîâ íåòðóäîñïîñîáíîñòè, â ñëó÷àå åñëè æåíùèíà ðîæàëà íå ïî ìåñòó æèòåëüñòâà - ïðîñòàâëÿåòñÿ êðóãëàÿ ïå÷àòü)" èñêëþ÷èòü;

äîïîëíèòü íîâûìè ïóíêòàìè 10 è 11, èçëîæèâ èõ â ñëåäóþùåé ðåäàêöèè:

"10. Ïðè çàïîëíåíèè òàëîíà N 3-2 ðîäîâîãî ñåðòèôèêàòà:

10.1. ëèöåâîé ñòîðîíû:

â ï. 1 "Êåì âûäàí" óêàçûâàåòñÿ ïîëíîå íàèìåíîâàíèå è àäðåñ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò;

â ï. 2 "Äàòà âûäà÷è" óêàçûâàåòñÿ ÷èñëî, ìåñÿö, ãîä âûäà÷è ðîäîâîãî ñåðòèôèêàòà;

â ï. 3 "Ô.È.Î. ìàòåðè" óêàçûâàåòñÿ ïîëíîñòüþ, áåç ñîêðàùåíèé ôàìèëèÿ, èìÿ, îò÷åñòâî æåíùèíû â ñîîòâåòñòâèè ñ äîêóìåíòîì, óäîñòîâåðÿþùèì åå ëè÷íîñòü;

â ï. 4 "ÑÍÈËÑ ìàòåðè" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ñâèäåòåëüñòâà ãîñóäàðñòâåííîãî ïåíñèîííîãî ñòðàõîâàíèÿ æåíùèíû;

â ï. 5 "Íîìåð ïîëèñà ÎÌÑ ìàòåðè" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ïîëèñà îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ æåíùèíû;

â ï. 6 "Íàèìåíîâàíèå ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû" óêàçûâàåòñÿ ïîëíîå íàèìåíîâàíèå è àäðåñ ðîäèëüíîãî äîìà, â êîòîðîì æåíùèíå áûëà ïðåäîñòàâëåíà ìåäèöèíñêàÿ ïîìîùü â ïåðèîä ðîäîâ;

â ï. 7 "Äàòà ðîæäåíèÿ ðåáåíêà (äàòà ðîäîâ)" óêàçûâàåòñÿ ÷èñëî, ìåñÿö, ãîä ðîæäåíèÿ ðåáåíêà;

â ï. 8 "Ô.È.Î. ðåáåíêà" óêàçûâàåòñÿ ïîëíîñòüþ, áåç ñîêðàùåíèé ôàìèëèÿ, èìÿ, îò÷åñòâî ðåáåíêà;

â ï. 9 "Íîìåð ïîëèñà ÎÌÑ ðåáåíêà" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ïîëèñà îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ ðåáåíêà;

â ï. 10 "Íàèìåíîâàíèå ËÏÓ" óêàçûâàåòñÿ ïîëíîå íàèìåíîâàíèå è àäðåñ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà, ëèáî ñòàâèòñÿ åãî øòàìï;

â ï. 11 "Ïåðèîä äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà" óêàçûâàþòñÿ äàòû (÷èñëî, ìåñÿö è ãîä) íà÷àëà è îêîí÷àíèÿ äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà â òå÷åíèå âòîðûõ øåñòè ìåñÿöåâ åãî æèçíè.

Òàëîí N 3-2 ðîäîâîãî ñåðòèôèêàòà ñ ëèöåâîé ñòîðîíû çàâåðÿåòñÿ ïîäïèñüþ ðóêîâîäèòåëÿ è ïå÷àòüþ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà, ïðîñòàâëÿåìîé â ïðàâîì íèæíåì óãëó;

10.2. îáîðîòíîé ñòîðîíû, çàïîëíÿåìîé òîëüêî â ñëó÷àå ðîæäåíèÿ æåíùèíîé äâîéíè è áîëåå äåòåé è âêëþ÷àþùåé ñâåäåíèÿ î âòîðîì è ïîñëåäóþùèõ äåòÿõ:

â ïóíêòàõ 8.1, 8.2, 8.3 "Ô.È.Î. ðåáåíêà" óêàçûâàåòñÿ ïîëíîñòüþ, áåç ñîêðàùåíèé ôàìèëèÿ, èìÿ, îò÷åñòâî âòîðîãî è ïîñëåäóþùèõ äåòåé;

â ïóíêòàõ 9.1, 9.2, 9.3 "Íîìåð ïîëèñà ÎÌÑ ðåáåíêà" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ïîëèñà îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ âòîðîãî è ïîñëåäóþùèõ äåòåé;

â ïóíêòàõ 11.1, 11.2, 11.3 "Ïåðèîä äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà" óêàçûâàþòñÿ äàòû (÷èñëî, ìåñÿö è ãîä) íà÷àëà è îêîí÷àíèÿ äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà â òå÷åíèå âòîðûõ øåñòè ìåñÿöåâ åãî æèçíè.

Òàëîí N 3-2 ðîäîâîãî ñåðòèôèêàòà ñ îáîðîòíîé ñòîðîíû â ñëó÷àå åå çàïîëíåíèÿ çàâåðÿåòñÿ ïîäïèñüþ ðóêîâîäèòåëÿ è ïå÷àòüþ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå äåòåé, ïðîñòàâëÿåìîé â ïðàâîì íèæíåì óãëó.

 ñëó÷àå, åñëè îáîðîòíàÿ ñòîðîíà íå ïîäëåæèò çàïîëíåíèþ, òî îíà ïîãàøàåòñÿ ñëåäóþùèì îáðàçîì: "Z".

11. Ïðè çàïîëíåíèè òàëîíà N 3-1 ðîäîâîãî ñåðòèôèêàòà:

11.1. ëèöåâîé ñòîðîíû:

â ï. 1 "Êåì âûäàí" óêàçûâàåòñÿ ïîëíîå íàèìåíîâàíèå è àäðåñ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò;

â ï. 2 "Äàòà âûäà÷è" óêàçûâàåòñÿ ÷èñëî, ìåñÿö, ãîä âûäà÷è ðîäîâîãî ñåðòèôèêàòà;

â ï. 3 "Ô.È.Î. ìàòåðè" óêàçûâàåòñÿ ïîëíîñòüþ, áåç ñîêðàùåíèé ôàìèëèÿ, èìÿ, îò÷åñòâî æåíùèíû;

â ï. 4 "ÑÍÈËÑ ìàòåðè" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ñâèäåòåëüñòâà ãîñóäàðñòâåííîãî ïåíñèîííîãî ñòðàõîâàíèÿ æåíùèíû;

â ï. 5 "Íîìåð ïîëèñà ÎÌÑ ìàòåðè" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ïîëèñà îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ æåíùèíû;

â ï. 6 "Íàèìåíîâàíèå ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû" óêàçûâàåòñÿ ïîëíîå íàèìåíîâàíèå è àäðåñ ðîäèëüíîãî äîìà, â êîòîðîì æåíùèíå áûëà ïðåäîñòàâëåíà ìåäèöèíñêàÿ ïîìîùü â ïåðèîä ðîäîâ;

â ï. 7 "Äàòà ðîæäåíèÿ ðåáåíêà (äàòà ðîäîâ)" óêàçûâàåòñÿ ÷èñëî, ìåñÿö, ãîä ðîæäåíèÿ ðåáåíêà;

â ï. 8 "Ô.È.Î. ðåáåíêà" óêàçûâàåòñÿ ïîëíîñòüþ, áåç ñîêðàùåíèé ôàìèëèÿ, èìÿ, îò÷åñòâî ðåáåíêà;

â ï. 9 "Íîìåð ïîëèñà ÎÌÑ ðåáåíêà" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ïîëèñà îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ ðåáåíêà;

â ï. 10 "Íàèìåíîâàíèå ËÏÓ" óêàçûâàåòñÿ ïîëíîå íàèìåíîâàíèå è àäðåñ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà, ëèáî ñòàâèòñÿ åãî øòàìï;

â ï. 11 "Ïåðèîä äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà" óêàçûâàþòñÿ äàòû (÷èñëî, ìåñÿö è ãîä) íà÷àëà è îêîí÷àíèÿ äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà â òå÷åíèå ïåðâûõ øåñòè ìåñÿöåâ åãî æèçíè.

Òàëîí N 3-1 ðîäîâîãî ñåðòèôèêàòà ñ ëèöåâîé ñòîðîíû çàâåðÿåòñÿ ïîäïèñüþ ðóêîâîäèòåëÿ è ïå÷àòüþ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà, ïðîñòàâëÿåìîé â ïðàâîì íèæíåì óãëó;

11.2. îáîðîòíîé ñòîðîíû, çàïîëíÿåìîé òîëüêî â ñëó÷àå ðîæäåíèÿ æåíùèíîé äâîéíè è áîëåå äåòåé, è âêëþ÷àþùåé ñâåäåíèÿ î âòîðîì è ïîñëåäóþùèõ äåòÿõ:

â ïóíêòàõ 8.1, 8.2, 8.3 "Ô.È.Î. ðåáåíêà" óêàçûâàåòñÿ ïîëíîñòüþ, áåç ñîêðàùåíèé ôàìèëèÿ, èìÿ, îò÷åñòâî âòîðîãî è ïîñëåäóþùèõ äåòåé;

â ïóíêòàõ 9.1, 9.2, 9.3 "Íîìåð ïîëèñà ÎÌÑ ðåáåíêà" óêàçûâàåòñÿ íîìåð ñòðàõîâîãî ïîëèñà îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ âòîðîãî è ïîñëåäóþùèõ äåòåé;

â ïóíêòàõ 11.1, 11.2, 11.3 "Ïåðèîä äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà" óêàçûâàþòñÿ äàòû (÷èñëî, ìåñÿö è ãîä) íà÷àëà è îêîí÷àíèÿ äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà â òå÷åíèå ïåðâûõ øåñòè ìåñÿöåâ åãî æèçíè.

Òàëîí N 3-1 ðîäîâîãî ñåðòèôèêàòà ñ îáîðîòíîé ñòîðîíû â ñëó÷àå åå çàïîëíåíèÿ çàâåðÿåòñÿ ïîäïèñüþ ðóêîâîäèòåëÿ è ïå÷àòüþ ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå äåòåé, ïðîñòàâëÿåìîé â ïðàâîì íèæíåì óãëó.

 ñëó÷àå åñëè îáîðîòíàÿ ñòîðîíà íå ïîäëåæèò çàïîëíåíèþ, òî îíà ïîãàøàåòñÿ ñëåäóþùèì îáðàçîì: "Z".".

Ïóíêò 10 ñ÷èòàòü ïóíêòîì 12.

 ïóíêòå 12 ïîñëå ñëîâ "íå áîëåå äâóõ èñïðàâëåíèé" äîïîëíèòü ñëîâàìè "â îäíîé ÷àñòè ðîäîâîãî ñåðòèôèêàòà".

 

 

 

 

 

Ïðèëîæåíèå

ê èçìåíåíèÿì, âíîñèìûì â Ïðèêàç

Ìèíèñòåðñòâà çäðàâîîõðàíåíèÿ

è ñîöèàëüíîãî ðàçâèòèÿ

Ðîññèéñêîé Ôåäåðàöèè

îò 28 íîÿáðÿ 2005 ã. N 701

"Î ðîäîâîì ñåðòèôèêàòå"

 

"Ïðèëîæåíèå N 1

ê Ïðèêàçó

Ìèíèñòåðñòâà çäðàâîîõðàíåíèÿ

è ñîöèàëüíîãî ðàçâèòèÿ

Ðîññèéñêîé Ôåäåðàöèè

îò 28 íîÿáðÿ 2005 ã. N 701

 

ÔÎÐÌÀ ÐÎÄÎÂÎÃÎ ÑÅÐÒÈÔÈÊÀÒÀ

 

           Êîðåøîê ÐÎÄÎÂÎÃÎ ÑÅÐÒÈÔÈÊÀÒÀ

                                                                           Á 0000000

ç      Ô.È.Î. ______________________________________________________________________________

à                                            (ïîëíîñòüþ)

ï      Àäðåñ ðåãèñòðàöèè ìåñòà æèòåëüñòâà __________________________________________________

î                                                                  ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

ë                                                Íîìåð ïîëèñà ÎÌÑ: │ │ │ │ │ │ │ │ │ │ │ │ │

í                                                                  └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

ÿ                ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┐                     ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

å      ÑÍÈËÑ     │ │ │ │-│ │ │ │-│ │ │ │ │ │ │                     │ │ │ │ │ │ │ │ │ │ │ │ │

ò                └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┘                     └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

ñ                  ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

ÿ      Äàòà âûäà÷è │ │ │ │ │ │ │ │ │ │ │         Ðàñïèñêà ïîëó÷àòåëÿ _______________________

                   └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

Ë

Ï      -------------------------------------------------------------------------------------

Ó                                          ëèíèÿ îòðåçà

,      -------------------------------------------------------------------------------------

 

î                             ÒÀËÎÍ N 1 ÐÎÄÎÂÎÃÎ ÑÅÐÒÈÔÈÊÀÒÀ

ñ                  (íà îïëàòó óñëóã ïî ìåäèöèíñêîé ïîìîùè, îêàçûâàåìîé     Á 0000000

ó                          â ïåðèîä íàáëþäåíèÿ æåíùèíû äî ðîäîâ)

ù

å      1. Êåì âûäàí ________________________________________________

ñ                    (íàèìåíîâàíèå ËÏÓ, îñóùåñòâëÿþùåãî íàáëþäåíèå

ò                      çà áåðåìåííîé æåíùèíîé è âûäàâøåãî ðîäîâûé

â                                     ñåðòèôèêàò)

ë                         ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐                        ┌─┬─┐

ÿ      2. Äàòà âûäà÷è     │ │ │ │ │ │ │ │ │ │ │ 3. Ñðîê áåðåìåííîñòè   │ │ │

þ                         └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                        └─┴─┘

ù                                                            (íåäåëü, íà ìîìåíò âûäà÷è

è                                                                   ñåðòèôèêàòà)

ì                         ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

       4. Äàòà ïîñòàíîâêè │ │ │ │ │ │ │ │ │ │ │                    ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

í      íà ó÷åò            └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                    │ │ │ │ │ │ │ │ │ │ │ │ │

à                                                                  └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

á                ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┐            6. Íîìåð ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

ë      5. ÑÍÈËÑ  │ │ │ │-│ │ │ │-│ │ │ │ │ │ │            ïîëèñà   │ │ │ │ │ │ │ │ │ │ │ │ │

þ                └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┘            ÎÌÑ:     └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

ä      7. Ô.È.Î. ___________________________________________________________________________

å                                                (ïîëíîñòüþ)

í                         ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

è      8. Äàòà ðîæäåíèÿ   │ │ │ │ │ │ │ │ │ │ │

å      æåíùèíû            └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

       9. Äîêóìåíò, óäîñòîâåðÿþùèé ëè÷íîñòü ________________________________________________

ç                                             (íàçâàíèå, ñåðèÿ, íîìåð, êåì è êîãäà âûäàí)

à      10. Àäðåñ ðåãèñòðàöèè ìåñòà          ________________________________________________

       æèòåëüñòâà

 

á      ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ _______________________                ÏÅ×ÀÒÜ ËÏÓ

å

ð      -------------------------------------------------------------------------------------

å                                          ëèíèÿ îòðåçà

ì      -------------------------------------------------------------------------------------

å

í                              ÒÀËÎÍ N 2 ÐÎÄÎÂÎÃÎ ÑÅÐÒÈÔÈÊÀÒÀ                         âûäà-

í                    (íà îïëàòó óñëóã ïî ìåäèöèíñêîé ïîìîùè, îêàçûâàåìîé    Á 0000000 åòñÿ

î                                 â ïåðèîä ðîäîâ æåíùèíû)                             æåí-

é                                                                                     ùèíå

       1. Êåì âûäàí ________________________________________________                  íà

                    (íàèìåíîâàíèå ËÏÓ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò)                  ðóêè

                          ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐             ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ âìåñ-

       2. Äàòà âûäà÷è     │ │ │ │ │ │ │ │ │ │ │             │ │ │ │ │ │ │ │ │ │ │ │ │ òå ñ

                          └─┴─┘.└─┴─┘.└─┴─┴─┴─┘             └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ ðîäî-

                 ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┐     4. Íîìåð ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ âûì

       3. ÑÍÈËÑ  │ │ │ │-│ │ │ │-│ │ │ │ │ │ │     ïîëèñà   │ │ │ │ │ │ │ │ │ │ │ │ │ ñåð-

                 └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┘     ÎÌÑ:     └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ òèôè-

       5. Ô.È.Î. ____________________________________________________________________ êàòîì

                                          (ïîëíîñòüþ)                                 è òà-

                          ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐                                       ëîíà-

       6. Äàòà ðîæäåíèÿ   │ │ │ │ │ │ │ │ │ │ │                                       ìè NN

       æåíùèíû            └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                                       3-1,

       7. Äîêóìåíò, óäîñòîâåðÿþùèé ëè÷íîñòü _________________________________________ 3-2

                                              (íàçâàíèå, íîìåð, ñåðèÿ, êåì è êîãäà    äëÿ

                                                               âûäàí)                 ïåðå-

       8. Àäðåñ ðåãèñòðàöèè ìåñòà           _________________________________________ äà÷è

       æèòåëüñòâà                                                                     â ðîä-

                                                                                      äîì

       ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, îñóùåñòâëÿþùåãî íàáëþäåíèå äî ðîäîâ _____ ÏÅ×ÀÒÜ ËÏÓ (îòäå-

 -------------------------------------                                                ëå-

 -------------------------------------                                                íèå)

 çà-   9. Íàèìåíîâàíèå ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû ________________________________

 ïîëíÿ-               ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐                 ┌─┬─┬─┬─┬─┐

 åòñÿ  10. Äàòà ðîäîâ │ │ │ │ │ │ │ │ │ │ │ 11. Èñõîä ðîäîâ │ │ │ │ │ │ (êîä ïî

 ïî                   └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                 └─┴─┴─┴─┴─┘ ÌÊÁ-10)

 ìåñòó

 ðîäîâ ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû ________________ ÏÅ×ÀÒÜ ËÏÓ

 

--------------------------------------------------------------------------------------------

                                       ëèíèÿ îòðåçà

--------------------------------------------------------------------------------------------

 

                                    ÐÎÄÎÂÛÉ ÑÅÐÒÈÔÈÊÀÒ

                                                                           Á 0000000

 

       1. Ô.È.Î. _________________________________________________

                 ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┐            3. Íîìåð ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

       2. ÑÍÈËÑ  │ │ │ │-│ │ │ │-│ │ │ │ │ │ │            ïîëèñà   │ │ │ │ │ │ │ │ │ │ │ │ │

                 └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┘            ÎÌÑ:     └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

                                                                   ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

                                                                   │ │ │ │ │ │ │ │ │ │ │ │ │

                                                                   └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

       4. Êåì âûäàí ________________________________________________________________________

                                (íàèìåíîâàíèå ËÏÓ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò)

                          ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

       5. Äàòà âûäà÷è     │ │ │ │ │ │ │ │ │ │ │

                          └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

       6. Íàèìåíîâàíèå ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû _______________________________________

                          ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐                    ┌─┬─┐ ┌─┬─┐

       7. Äàòà ðîäîâ      │ │ │ │ │ │ │ │ │ │ │     8. Âðåìÿ ðîäîâ │ │ │ │ │ │

                          └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                    └─┴─┘ └─┴─┘

       9. ÑÂÅÄÅÍÈß Î ÐÅÁÅÍÊÅ: Ïîë    _________   _________   _________

                              Ðîñò   _________   _________   _________

                              Âåñ    _________   _________   _________

                                                           ┌─┬─┐

       10. ×èñëî äåòåé ó æåíùèíû, âêëþ÷àÿ ðîæäåííûõ ðàíåå  │ │ │

                                                           └─┴─┘

 

       ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû ________________ ÏÅ×ÀÒÜ ËÏÓ

 

--------------------------------------------------------------------------------------------

                                       ëèíèÿ îòðåçà

--------------------------------------------------------------------------------------------

 

                             ÒÀËÎÍ N 3-2 ÐÎÄÎÂÎÃÎ ÑÅÐÒÈÔÈÊÀÒÀ                         âûäà-

                        (íà îïëàòó óñëóã çà âòîðûå øåñòü ìåñÿöåâ           Á 0000000  åòñÿ

                             äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà)                        æåí-

                                                                                      ùèíå

ç      1. Êåì âûäàí ________________________________________________                  íà

à                   (íàèìåíîâàíèå ËÏÓ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò)                  ðóêè

ï                         ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐                                       âìåñ-

î      2. Äàòà âûäà÷è     │ │ │ │ │ │ │ │ │ │ │                                       òå ñ

ë                         └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                                       ðîäî-

í      3. Ô.È.Î. ìàòåðè _____________________________________________________________ âûì

ÿ                                              (ïîëíîñòüþ)                            ñåð-

å                ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┐     5. Íîìåð ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ òèôè-

ò      4. ÑÍÈËÑ  │ │ │ │-│ │ │ │-│ │ │ │ │ │ │     ïîëèñà   │ │ │ │ │ │ │ │ │ │ │ │ │ êàòîì

ñ         ìàòåðè └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┘     ÎÌÑ      └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äëÿ

ÿ                                                  ìàòåðè   ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ ïåðå-

                                                            │ │ │ │ │ │ │ │ │ │ │ │ │ äà÷è

Ë                                                           └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ â

Ï      6. Íàèìåíîâàíèå ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû ________________________________ äåòñ-

Ó                           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐                                     êîå

,      7. Äàòà ðîæäåíèÿ     │ │ │ │ │ │ │ │ │ │ │                                     ëå-

       ðåáåíêà (äàòà ðîäîâ) └─┴─┘.└─┴─┘.└─┴─┴─┴─┘                                     ÷åá-

î      8. Ô.È.Î. ðåáåíêà ____________________________________________________________ íîå

ñ                                (ïîëíîñòüþ. Ïðè ðîæäåíèè äâîéíè è áîëåå äåòåé        ó÷-

ó                                     çàïîëíÿåòñÿ îáîðîòíàÿ ñòîðîíà òàëîíà)           ðåæ-

ù                                  ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                          äåíèå

å      9. Íîìåð ïîëèñà ÎÌÑ ðåáåíêà │ │ │ │ │ │ │ │ │ │ │ │ │

ñ                                  └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

ò                                  ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

â                                  │ │ │ │ │ │ │ │ │ │ │ │ │

ë                                  └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

ÿ      10. Íàèìåíîâàíèå ËÏÓ _________________________________________________________

þ                               (îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà)

ù                                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐    ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

è      11. Ïåðèîä äèñïàíñåðíîãî      ñ │ │ │ │ │ │ │ │ │ │ │ ïî │ │ │ │ │ │ │ │ │ │ │

ì      íàáëþäåíèÿ ðåáåíêà:             └─┴─┘.└─┴─┘.└─┴─┴─┴─┘    └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

 

ä      ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, îñóùåñòâëÿâøåãî äèñïàíñåðíîå

è                                          íàáëþäåíèå ðåáåíêà ____________ ÏÅ×ÀÒÜ ËÏÓ

ñ

ï -----------------------------------------------------------------------------------

à                                      ëèíèÿ îòðåçà

í -----------------------------------------------------------------------------------

ñ

å                            ÒÀËÎÍ N 3-1 ÐÎÄÎÂÎÃÎ ÑÅÐÒÈÔÈÊÀÒÀ

ð                       (íà îïëàòó óñëóã çà ïåðâûå øåñòü ìåñÿöåâ           Á 0000000

í                            äèñïàíñåðíîãî íàáëþäåíèÿ ðåáåíêà)

î

å      1. Êåì âûäàí ________________________________________________

                    (íàèìåíîâàíèå ËÏÓ, âûäàâøåãî ðîäîâûé ñåðòèôèêàò)

í                         ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

à      2. Äàòà âûäà÷è     │ │ │ │ │ │ │ │ │ │ │

á                         └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

ë      3. Ô.È.Î. ìàòåðè _____________________________________________________________

þ                                              (ïîëíîñòüþ)

ä                ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┬─┐ ┌─┬─┐     5. Íîìåð ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

å      4. ÑÍÈËÑ  │ │ │ │-│ │ │ │-│ │ │ │ │ │ │     ïîëèñà   │ │ │ │ │ │ │ │ │ │ │ │ │

í         ìàòåðè └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┘     ÎÌÑ      └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

è                                                  ìàòåðè   ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

å                                                           │ │ │ │ │ │ │ │ │ │ │ │ │

                                                            └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

ð      6. Íàèìåíîâàíèå ËÏÓ, â êîòîðîì ïðîõîäèëè ðîäû ________________________________

å                           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

á      7. Äàòà ðîæäåíèÿ     │ │ │ │ │ │ │ │ │ │ │

å      ðåáåíêà (äàòà ðîäîâ) └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

í      8. Ô.È.Î. ðåáåíêà ____________________________________________________________

ê                               (ïîëíîñòüþ. Ïðè ðîæäåíèè äâîéíè è áîëåå äåòåé

à                                     çàïîëíÿåòñÿ îáîðîòíàÿ ñòîðîíà òàëîíà)

                                   ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

       9. Íîìåð ïîëèñà ÎÌÑ ðåáåíêà │ │ │ │ │ │ │ │ │ │ │ │ │

                                   └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

                                   ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐

                                   │ │ │ │ │ │ │ │ │ │ │ │ │

                                   └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘

       10. Íàèìåíîâàíèå ËÏÓ _________________________________________________________

                                (îñóùåñòâëÿþùåãî äèñïàíñåðíîå íàáëþäåíèå ðåáåíêà)

                                       ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐    ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

       11. Ïåðèîä äèñïàíñåðíîãî      ñ │ │ │ │ │ │ │ │ │ │ │ ïî │ │ │ │ │ │ │ │ │ │ │

       íàáëþäåíèÿ ðåáåíêà:             └─┴─┘.└─┴─┘.└─┴─┴─┴─┘    └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

 

       ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, îñóùåñòâëÿâøåãî äèñïàíñåðíîå

                                           íàáëþäåíèå ðåáåíêà ____________ ÏÅ×ÀÒÜ ËÏÓ

 

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Îáîðîòíàÿ ñòîðîíà òàëîíà N 3-2 ðîäîâîãî ñåðòèôèêàòà

 

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                                       ëèíèÿ îòðåçà

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Çà-                         Ñâåäåíèÿ î âòîðîì è ïîñëåäóþùèõ äåòÿõ:

ïîë-

íÿ-   8.1. Ô.È.Î. ðåáåíêà __________________________________________________________________

åòñÿ                                                (ïîëíîñòüþ)

â                       ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

ñëó-  9.1. Íîìåð ïîëèñà │ │ │ │ │ │ │ │ │ │ │ │ │ 11.1. Ïåðèîä      ñ  │ │ │ │ │ │ │ │ │ │ │

÷àå         ÎÌÑ ðåáåíêà └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äèñïàíñåðíîãî        └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

ðîæ-                    ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ íàáëþäåíèÿ           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

äå-                     │ │ │ │ │ │ │ │ │ │ │ │ │ ðåáåíêà           ïî │ │ │ │ │ │ │ │ │ │ │

íèÿ                     └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘                      └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

äâî-  8.2. Ô.È.Î. ðåáåíêà __________________________________________________________________

éíè                                                 (ïîëíîñòüþ)

è                       ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

áî-   9.2. Íîìåð ïîëèñà │ │ │ │ │ │ │ │ │ │ │ │ │ 11.2. Ïåðèîä      ñ  │ │ │ │ │ │ │ │ │ │ │

ëåå         ÎÌÑ ðåáåíêà └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äèñïàíñåðíîãî        └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

äå-                     ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ íàáëþäåíèÿ           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

òåé                     │ │ │ │ │ │ │ │ │ │ │ │ │ ðåáåíêà           ïî │ │ │ │ │ │ │ │ │ │ │

                        └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘                      └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

      8.3. Ô.È.Î. ðåáåíêà __________________________________________________________________

                                                (ïîëíîñòüþ)

                        ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

      9.3. Íîìåð ïîëèñà │ │ │ │ │ │ │ │ │ │ │ │ │ 11.3. Ïåðèîä      ñ  │ │ │ │ │ │ │ │ │ │ │

            ÎÌÑ ðåáåíêà └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äèñïàíñåðíîãî        └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

                        ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ íàáëþäåíèÿ           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

                        │ │ │ │ │ │ │ │ │ │ │ │ │ ðåáåíêà           ïî │ │ │ │ │ │ │ │ │ │ │

                        └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘                      └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

 

      ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, îñóùåñòâëÿâøåãî äèñïàíñåðíîå

                                          íàáëþäåíèå ðåáåíêà ____________ ÏÅ×ÀÒÜ ËÏÓ

 

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Îáîðîòíàÿ ñòîðîíà òàëîíà N 3-1 ðîäîâîãî ñåðòèôèêàòà

 

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                                       ëèíèÿ îòðåçà

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Çà-                         Ñâåäåíèÿ î âòîðîì è ïîñëåäóþùèõ äåòÿõ:

ïîë-

íÿ-   8.1. Ô.È.Î. ðåáåíêà __________________________________________________________________

åòñÿ                                              (ïîëíîñòüþ)

â                       ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

ñëó-  9.1. Íîìåð ïîëèñà │ │ │ │ │ │ │ │ │ │ │ │ │ 11.1. Ïåðèîä      ñ  │ │ │ │ │ │ │ │ │ │ │

÷àå         ÎÌÑ ðåáåíêà └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äèñïàíñåðíîãî        └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

ðîæ-                    ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ íàáëþäåíèÿ           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

äå-                     │ │ │ │ │ │ │ │ │ │ │ │ │ ðåáåíêà           ïî │ │ │ │ │ │ │ │ │ │ │

íèÿ                     └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘                      └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

äâî-  8.2. Ô.È.Î. ðåáåíêà __________________________________________________________________

éíè                                               (ïîëíîñòüþ)

è                       ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

áî-   9.2. Íîìåð ïîëèñà │ │ │ │ │ │ │ │ │ │ │ │ │ 11.2. Ïåðèîä      ñ  │ │ │ │ │ │ │ │ │ │ │

ëåå         ÎÌÑ ðåáåíêà └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äèñïàíñåðíîãî        └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

äå-                     ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ íàáëþäåíèÿ           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

òåé                     │ │ │ │ │ │ │ │ │ │ │ │ │ ðåáåíêà           ïî │ │ │ │ │ │ │ │ │ │ │

                        └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘                      └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

      8.3. Ô.È.Î. ðåáåíêà __________________________________________________________________

                                                  (ïîëíîñòüþ)

                        ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐                      ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

      9.3. Íîìåð ïîëèñà │ │ │ │ │ │ │ │ │ │ │ │ │ 11.3. Ïåðèîä      ñ  │ │ │ │ │ │ │ │ │ │ │

            ÎÌÑ ðåáåíêà └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ äèñïàíñåðíîãî        └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

                        ┌─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┬─┐ íàáëþäåíèÿ           ┌─┬─┐ ┌─┬─┐ ┌─┬─┬─┬─┐

                        │ │ │ │ │ │ │ │ │ │ │ │ │ ðåáåíêà           ïî │ │ │ │ │ │ │ │ │ │ │

                        └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘                      └─┴─┘.└─┴─┘.└─┴─┴─┴─┘

 

      ÏÎÄÏÈÑÜ ÐÓÊÎÂÎÄÈÒÅËß ËÏÓ, îñóùåñòâëÿâøåãî äèñïàíñåðíîå

                                          íàáëþäåíèå ðåáåíêà ____________ ÏÅ×ÀÒÜ ËÏÓ

 

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