Maternal Care Patient Case Form

Welcome to ECHO Idaho's Maternal 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 patient/client specific, Personally Identifiable Information (PII) nor Protected Health Information (PHI). If you have any questions regarding this form, please contact echoidaho@uidaho.edu.

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.

Do not include any identifiable patient/client information, Personally Identifiable Information (PII), or Protected Health Information (PHI) or information protected by The Family Educational Rights and Privacy Act (FERPA). If you have any questions regarding this form, please contact echoidaho@uidaho.edu. *

Click here to acknowledge.

Is this a new patient case or a follow-up to a previously presented case? *

New patient case

Follow-up to a previously presented case

What specific treatment questions do you have for ECHO?

Age

Gender identity

Relevant medical history (family history, pre-existing health conditions, pregnancy-related health conditions, etc.):

Current medications (include dose and length of time used):

Relevant social history (employment, housing, education, support systems, etc.):

Other pertinent information:

Patient goals for treatment:

Provider goals for treatment:

What progress has your patient made since your initial presentation?

Have you or the patient 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 Maternal Care 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) appears in answers on the above form, 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.

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