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Get Health Partners Chemical Continued Service Request Form

I: Axis II: Axis III: Axis IV: Axis V: Dimension 1: Acute Intoxication and/or Withdrawal Risk Level: Last Use Date: Are there any current withdrawal concerns? If yes, current withdrawal concerns include: Was member given any w/d medications? Dimension 2: Biomedical Conditions and Complications Risk Level: Current Medical concerns: Current medical medications: Current medical concerns that require 24 hour care: H UR Material CD Reviews Form - Chemical Health Continued Service Request Fo.

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