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.

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The following asks questions regarding your patient/client's demographic information

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.