1 Start 2 page break 3 Preview 4 Complete Welcome to ECHO Idaho's STAT Consultation Patient 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 * 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. Do you have a general question or specific patient-related question? * General question Patient specific question What is the question you would like to ask the expert panel? Leave this field blank
