PAYER CARD [Illegible] [Illegible}

Date/Signature
Infectious diseases from group Ongoing
Reason for refusing payment A/which require isolation
measures to be taken Initial/follow-up previous
certificate series/no

CERTIFICATE OF MEDICAL LEAVE Series CCMAO No 1576171

For the date 05 MAY Year 2021 for compensation code (1-15) 01 ZERO ONE
(month) (in letters)
First and last name BAICU CARMEN MARIA
Provided as evidence for social security contribution code for VALCEA
Personal identity code 2880519384964
Personal identity code of the sick child:

Acute
Subacute
Chronic
Domicile, residence: City DĂGĂȘANI
Street ALEEA VIITORULUI No 1 Block Staircase Floor Apartment County/Sector VALCEA
[Illegible] Date issued No of days From Until Diagnosis code
9
Inpatient/date 21/05/21 18 06/05/21 23/05/21 648
admitted…….. Stamp
[HOSPITAL FOR
External medica facility CHRONIC ILLNESSES
ZZLLAA CĂLINEȘTI 2 ZZLLAAZZLLAA
ARGEȘ COUNTY
Issuing medical facility Convention no 409/2014 with social security contribution code VALCEA
Doctor/Signature/Stamp Chief ward physician/Signature/Stamp
[illegible stamp] [illegible stamp]

Unique registration code Stamp code Stamp code

Issuing facility:………………. General Director Chief Physician

(name, signature) (name, signature)
……………………… ……………………...
INSURER:____________ Registered office:______________ Unique registration code:
Employees:
Salaried: Article 1 para (1) lit. A from the Emergency government ordinance no 158/2005
regarding leaves of absence and compensation for health-related social security
Salaried: Article 1 para (1) lit. B from the Emergency government ordinance no 158/2005
regarding leaves of absence and compensation for health-related social security
Employed Unemployed
Persons covered under Article 1 para (2), Article 23 para (2) and Article 32 from emergency government ordinance
no 158/2005 regarding leaves of absence and compensation for health-related social security
Insured in accordance with Law no 346/2002 regarding insurance for work-related accidents and occupational illnesses
Percentage paid: 75% 80% 85% 100% Prevented
Daily average based on the calculation Total health-related social
Calculation of compensation for health-related social security Days for work-related social security security compensation/
based on the calculation of insurance compensation for for calculation compensation/Daily average based on Total social security
work-related accidents and occupational illnesses basis the calculation for compensation for compensation owed due to
insurance owed due to work-related work-related accidents or
accidents and occupational illnesses occupational illnesses

Compensation paid by employees Compensation paid by the FNUASS budget Compensation paid by an insurance fund for
for leaves of absence and compensation work-related accidents and occupational illnesses
Days Days Lei Days Lei

[illegible] Opinion of the Local Pension Fund Opinion of the Public Health Board Opinion regarding maternal risk leave
Occupational health physician/Signature-Stamp