Project ECHO for Interstitial Lung Disease

Case Form

Thank you for participating in Project ECHO for Interstitial Lung Disease.

Please answer as many questions as possible or as relevant, and please do not share any protected health information (PHI).

By submitting this form, you acknowledge that Project ECHO case discussions do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in an ECHO session. ECHO case discussions are intended solely for educational purposes and are not meant to serve as a consultation or as a mechanism for providing formal recommendations on treatment and other management decisions, which remain the sole responsibility of the treating provider.

Please email ECHO@ildcollaborative.org if you have any questions regarding this form.

For educational and quality improvement purposes, we will be maintaining a Data Repository of all submitted case presentation forms and de-identified supporting data. By submitting this form, you are consenting to the Pulmonary Care and Research Collaborative / ILD Collaborative collecting and housing your case presentation form and de-identified supporting data.