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BPregnancyb Notification BFormb Molina Healthcare 2016
Of pregnant uterus OB Panel OB/GYN recommended Date of First Prenatal Appointment Current Pregnancy Hypertension Diabetes Smoking Excessive Nausea/Vomiting 17 P Candidate If PTD Pre-term Labor Multiple Gestation Other Past Pregnancy History N/A Pre-term delivery Fetal Demise Pre-eclampsia or Toxemia PCPs need to include a pregnancy related diagnosis code with one of the above Provider Information Practitioner s Name IPA Name Referred to OB/GYN Practitioner Provider Signature Date Version 2....
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