Pharm SUD ECHO Systems Based Case

To submit a case, fill out the form below.

Prefer to complete it in your own time? Download this form and email it to the contact listed on the form.

If you have any questions about this case form, please contact ncushman@npaihb.org or echo@npaihb.org.

Your Name(Required)

Basic Information

MM slash DD slash YYYY

Describe the situation or challenge your practice has experienced addressing Substance Use Disorder (SUD) treatment or recovery services from a systems- or population-level. This could be related to administrative, scope of practice, workflow, referral, or other hurdles.

Please describe the current state of the system.
Please provide any additional information related to the situation or overall context.
Please state your current view on the situation.
Please state your main questions or concerns.

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. Always use Patient ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.

This field is for validation purposes and should be left unchanged.