1 Start 2 new page for Diabetes 3 New page met conditions 4 New Page for all 5 Complete Welcome to ECHO Idaho's Diabetes and Metabolic Conditions Case Submission Form.Please complete as much of the form as you can. We understand you might not have all the data. Please do not include any specific client specific of Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected]. Presenter First and Last Name Credentials Phone Number Clinical Site City Email ECHO Idaho offers $100 in compensation for case presentations. Would you like to accept compensation for presenting this case? Yes (ECHO staff will reach out to you with compensation paperwork that must be completed three weeks prior to your presentation date.) No, I would like to donate my time. You are responsible for ensuring that no identifiable patient/client information is included (e.g., photos, records), nor any Personally Identifiable Information (PII), Protected Health Information (PHI), or information protected under the Family Educational Rights and Privacy Act (FERPA). If you have any questions about this form, please contact [email protected]. Click here to acknowledge. KEY QUESTIONS FOR PANEL What specific questions or challenges would you like input on from the ECHO panel? (Diagnosis uncertainty? Medication selection? CGM initiation? Weight management? Metabolic syndrome?) PATIENT DEMOGRAPHICS Patient Age Sex at Birth Female Male Insurance Type Private Medicaid Medicare PRIMARY PROBLEM STATEMENT Does this patient have diabetes? Yes No Leave this field blank
