Oral Health 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 tmason@npaihb.org or echo@npaihb.org.

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Patient Information

Please enter a number from 0 to 125.
Current Medications:
Medication Name
Dosage
Frequency
 
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    PLEASE NOTE that case consultations do not create or otherwise establish a provider-patient relationship between any clinician and any patient whose case is being presented in this clinical setting. Always use ECHO ID when presenting a patient in clinic. Sharing patient name, initials, or other identifying information violates HIPAA privacy laws.

    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.