Emergency Medical Services ECHO - Indian Country ECHO

To submit a case, fill out the form below.

Prefer to complete it in your own time? Download this form and email it to the contact listed on the form.

If you have any questions about this case form, please contact echo@npaihb.org.

Presenter Name

Date

Contact Email(Required)

Presenter Role

Community

Does your question relate to a patient?

Yes

No

If yes, go to Section 1

Does your question relate to a procedure within your practice?

Yes

No

If yes, go to Section 2

Section 1

Brief summary of presenting case:

Significant past medical history or co-morbidities:

Current medications (if relevant):

What help would you like from the panel?

Section 2

Brief summary of presenting problem:

What help would you like from the panel?

By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session. Always use Patient ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.