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Urrent pregnancy is singleton and patient has a history of singleton spontaneous preterm birth less than 37 weeks of gestation)? Yes No Current Gestational Age: ICD-9 Code: weeks days Date recorded: v23.41 (pregnancy with a history of preterm labor) Is the patient currently on compounded HPC ( 17P )? Yes Other: No STEP 4 Complete and Sign Rx Clear Field Prescriber s Name (Last, First) NPI # Address Medicaid Provider # City State Z.

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