Disclosure Statement

PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any WVU clinician and any patient whose case is being presented in a Project ECHO setting. Always use ECHO ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.

HIV Case Presentation Form

General Information / Demographics

Case Presentation

Risk factors for HIV Infection/Transmission

Risk Factors (Please check all that apply.)







Labs

(if positive please upload below)

Vaccinations

Questions

Instructions

If you have any questions regarding the ECHO project, please send an email to Jay Mason, Mithra Mohtasham, or Elisabeth Minnick.