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Get Chemotherapy Order Form For HIP Drug ... - EmblemHealth

For NY ICORE is required to obtain a copy of an official NYS Rx. BSA m2 Patient Height cm Primary ICD-9 Code kg Secondary DX Hgb Level Gm/DI HCT Level ANC Level /mm3 Scr Her2 KRAS Mutated Ferritin Level ng/ml Yes No Last dose given // Date most current lab work // Labs may be requested if necessary. Allergies Other list NKA Drugs Strength/Frequency Note Drugs with asterisks indicate specific test results see above that must be submitted w.

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