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SPARC Case Presentation Form
Presenter's Name
Presenter's E-mail
Clinic/Facility Name
Clinic/ Facility City
Provider's Name (If different from Presenter)
Provider E-mail (If different from Presenter)
1st Choice Presentation Date
March 20, 2019
April 3, 2019
April 17, 2019
May 1, 2019
May 15, 2019
May 29, 2019
2nd Choice Date Presentation Date:
March 20, 2019
April 3, 2019
April 17, 2019
May 1, 2019
May 15, 2019
May 29, 2019
Patient Information
Patient Age
Patient Height
Patient weight
Patient BMI
Insurance?
🛈
Medicaid
Medicare
Commercial
No Insurance
Other
Other
Specific Request from ECHO team
🛈
Social Determinate of health
🛈
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