Emergency Medicine 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 ncushman@npaihb.org or echo@npaihb.org.

MM slash DD slash YYYY
Presenter Name(Required)

Patient Information

Sex at birth

Vital Signs

(room air, nasal cannula, etc)

Physical Exams

Diagnostics

LABS

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.

This field is for validation purposes and should be left unchanged.