1 Start 2 Complete Welcome to ECHO Idaho's Oral Health in Primary Care Case Submission Form.Complete as much of the form as you can. We understand you may not have all the details. Please do not include any client-specific 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 Email * Organization City, State * Please do not include any identifiable patient/client information, Personally Identifiable Information (PII) nor Protected Health Information (PHI). If you have any questions regarding this form, please contact [email protected]. * Click here to acknowledge. Patient Information List any specific questions related to diagnosis, treatment, or coordination of care. * Include relevant case details (e.g., pre-existing conditions, oral health 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 nor 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) nor 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 at the email address you provided. An ECHO staff member will contact you within two business days to discuss presenting your case in a session or scheduling a follow-up consultation with a panelist. Leave this field blank
