1 Start 2 Complete Welcome to ECHO Idaho's Oral Health in Primary Care 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]. Case Presenter Information Presenter First and Last Name * Credentials Presenter email * Organization City, State * Please do not include any identifiable patient/client information, Personally Identifiable Information (PII) or Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected]. * Click here to acknowledge. Patient Information What specific question(s) would you like the ECHO Idaho panel to address regarding this case? * Include relevant case details (e.g., oral health conditions, pre-existing conditions, head and neck cancer, etc.): Include relevant images (optional) Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf. Thank you for completing ECHO Idaho's Oral Health Case Submission Form.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.No personally identifiable health information (PHI) or personally identifiable information (PII) will appear on the above form when shared, in compliance with HIPAA privacy laws.You will receive a copy of your responses in the email you provided and be contacted by ECHO staff about presenting your case in a session or follow-up consultation with a panelist within two business days. Leave this field blank
