1 Start 2 Complete Welcome to ECHO Idaho's Online Opioids, Pain and Substance Use Disorders 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. 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 Please 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. The following asks questions regarding your patient/client's demographic 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 Opioids, Pain and Substance Use Disorders 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. Leave this field blank
