HCV Elimination Strategy Planning

Please 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.

Your Name(Required)
What information is needed (e.g. build cascade of care, positivity rate, percentage of population screened, patient panel)? Who will compile this information?
Identified needs?
Think about what settings (e.g. dental, community events, routine visits, age range)? With what staff?
Identified needs?
Think about what settings? With what staff (e.g. CHR, Peer specialist, Case Manager)?
Identified Needs?
Think about what settings (pharmacy window, nurse visit, MAT clinic, delivery)? With what staff?
Identified needs?
Think about what settings? With what staff (e.g. Primary Care, Behavioral Health, PH, Nursing)?
Identified needs?
Think about what settings? With what staff (e.g. Primary Care, Behavioral Health, PH, Nursing?)
Identified needs?
(include identified needs, how to address noted barriers, key stakeholders/champions, short/long term goals and implementation ideas)

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.