Modulo B bis
A cura del MMG

	DISTRETTO DI ______________________ - U.O.S. ASSISTENZA SANITARIA DI BASE
ASSISTENZA PROGRAMMATA AI PAZIENTI NON AMBULABILI
(Ai sensi dell’allegato G, artt. 45-53-59, ACN 23 marzo 2005 ed integrativo 29 luglio 2009)	

COMUNICAZIONI E/O VARIAZIONI

Medico:
Cognome
	Nome	Cod. reg.	

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Data …………………………			Timbro e Firma ……………………………………………….…