1 Start 2 Complete Welcome to ECHO Idaho's Substance Use Disorders 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 * Phone number * Organization City, State * 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. Please indicate if this is a new patient/client case or if this is a follow-up to a previously presented case. * New patient/client case Follow-up to a previously presented case Are you willing to present a follow-up on this case in 3 months? Yes No Maybe 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. I am looking for (select all that apply) * Help with diagnosis Help with treatment options Help with referrals Other... I am looking for (select all that apply) Other... Patient Information Age Gender identity Insurance: Medicare Medicaid, MCO Commercial Health Insurance None Other, please specify. Insurance: Other, please specify. Please include any relevant substance use history: Please include any relevant psychiatric history: Please include any other relevant background on your patient/client (physical abuse, family history, etc.): List current medications (include dose and length of time used): List past medications (include dose and length of time used): Medication Adherence: - None -ExcellentGoodFairPoor What specific treatment questions do you have for ECHO? Have you or the patient/client encountered any additional challenges or obstacles since you presented the case? If so, what were they? What follow-up questions do you have for ECHO? Thank you for completing ECHO Idaho's Substance Use Disorders 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
