Patient Case Presentation Form

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<p>Please complete this form ensuring that it <strong>does not contain any PHI or PII.</strong></p>
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Please let us know your name.

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Please write a subject for your message.

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Note: Please do not send protected health information (PHI) with your report. Please de-identify your reports of any patient identifiers.

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(received in the past two weeks - based on the individual case)

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(white blood cell count)

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(please fax relevant culture reports)

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When we receive your case, we will email or fax you a confidential patient ID number that must be utilized when identifying your patient during clinic.

PLEASE NOTE that case consultations do not create or otherwise establish a provider-patient relationship between any presenting clinician and any patient whose case is being presented in this setting.