Indian Health Service COVID-19 TeleECHO New Case Form

Please answer as many questions as possible and remember not to share any personal health information (PHI).

If you wish to save your entries and complete the form at another time, click "Save & Return Later" at the bottom of this form. Then enter your email address and use the link you receive to return at your convenience.

By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session.

For educational and quality improvement purposes, we will be maintaining a Data Repository of all submitted case presentation forms. By submitting this form, you are consenting to the ECHO Institute collecting and housing your case presentation form.

Please email ihsecho@salud.unm.edu if you have any questions regarding this form.

Program Email

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Date

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M-D-Y

Presenter's First Name:

Presenter's Last Name:

* must provide value

Email:

* must provide value

Organization:

Please state your question(s) for the network:

* must provide value

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Primary insurance:

* must provide value

Name of medicaid:

* must provide value

Secondary insurance:

* must provide value

Name of medicaid:

* must provide value

Sex at Birth:

Female

Male

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Gender Identity:

Age:

Weight (lbs):

Height (in):

BMI:

View equation

Date of COVID-19 Test Results:

M-D-Y

Duration of Isolation:

Comorbidities:

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Labs/Tests:

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Description of patient case:

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Please click the submit button below to send to the teleECHO program.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.