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Birth Weight g/kg/lbs Current Weight g/kg/lbs Date Recorded Please Document All Diagnoses and Document to the Highest Degree of ICD-9 Detail MEDICAL CRITERIA: 1. Diagnosis of Chronic Pulmonary Disease (CLD/BPD) & less than 24 months of age at Start of RSV Season? Yes No ICD-9 Is Patient Receiving Medical Treatment of: (Check all that apply and provide last date received) Oxygen Date Corticosteroids Date.

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