dEsSalud MULTIPLE MANAGEMENT FORM

Social Security for all

APPLICANT/REPRESENTATIVE DATA:

Last name Mother's last name Names

ID □ Immigration Card / Passport □ No.………………………………………………..
Home: ………………………………………….…………. Department: ………………… Province: ………………… District:…………………
Telephone/Cell.: ………………………... Relationship: ………………………………… Email: …………………………………………………

PATIENT INFORMATION (fill out only if different from the applicant):

1 1
Last name Mother's last name Names
ID □ Immigration Card / Passport 0 No. …………………………............................

SOLICITED SERVICE :
• Copy of Medical History D Medical Report
Q2| Copy of diagnostic aid results • Medical Evaluation of Adult Children with Total and Permanent Disability
for Work
• Birth Certificate • Medical Evaluation for Independent Agricultural, Poultry, Aquaculture or
Agroindustrial Workers Over Seventy (70) Years of Age.
□ Death Certificate • Medical Evaluation of Disabled Surviving Spouse and Children Over Eighteen
(18) Years of Age with Total and Permanent Disability for Work (monthly
bonus pension procedure-Law No. 20530.
□ Duplicate of the Certificate of Temporary Incapacity for Work • Medical Certificate for the Disability Pension Processing (Law 19990)
-CITT
Description of the request (Medical specialty, date, type of diagnostic aid examination required, others):

Documents attached:
Grades:
The patient's clinical information is reserved (Art. 25th Law No. 26842, General Health Law). The procedure is personal, if it is not possible, it may be
initiated by the immediate family member (spouse, children, parents or siblings) or duly accredited legal representative in accordance with the provisions
Proof of payment □ Simple Power of Other:………………………….
of article 5 of the Regulation of Law No.Attorney
29414, Law• that establishes the rights
……………………………………………………………….
of users of health services, approved by DS No. 027-2015-SA.

Date: ………………../……..………./
Signature of the applicant