Registration Form

AmeriHealth Caritas Louisiana is excited to launch TeleECHO™ clinics – an emerging case-based learning model for practitioners. This opportunity is free for participating AmeriHealth Caritas Louisiana practitioners.
Please complete and submit the form below to register as a TeleECHO clinic participant.

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* 1. Participant's First Name

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* 2. Participant's Last Name

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* 3. Address

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Phone Number

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* 8. Email Address

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* 9. License Type (Please put N/A if Not Applicable)

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* 10. License Number (Please put N/A if Not Applicable)

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* 11. NPI Number (Please put N/A if Not Applicable)

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* 12. What do you hope to learn or gain from participation in this project?

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* 13. Are there any particular topics you'd like to hear about during the didactic presentation part of the clinic?

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* 14. What is considered protected health information (PHI)? Please read this list and attest by checking the box below.

As a reminder, disclosed information is considered PHI if:
  • The information includes any of the data elements listed below (data elements may pertain to a patient and/or a patient’s family members). OR
  • The provider disclosing the information knows that the disclosed information could be used alone or in combination with other information to identify the patient.
(A) Names.

(B) All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP code, and their equivalent geocodes, except for the initial three digits of a ZIP code if, according to the current publicly available data from the Bureau of the Census:
  • (1) The geographic unit formed by combining all ZIP codes with the same three initial digits contains more than 20,000 people.
  • (2) The initial three digits of a ZIP code for all such geographic units containing 20,000 or fewer people is changed to 000.
(C) All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, and date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older.

(D) Phone numbers.

(E) Fax numbers.

(F) Email addresses.

(G) Social Security numbers.

(H) Medical record numbers.

(I) Health plan beneficiary numbers.

(J) Account numbers.

(K) Certificate/license numbers.

(L) Vehicle identifiers and serial numbers, including license plate numbers.

(M) Device identifiers and serial numbers.

(N) Web universal resource locators (URLs)

(O) Internet protocol (IP) address numbers.

(P) Biometric identifiers, including finger and voice prints.

(Q) Full face photographic images and any comparable images.

(R) Any other unique identifying number, characteristic, or code, except as permitted by paragraph (c) of this section.

As a reminder, the HIPAA Privacy Rule allows covered entities to access, use, or disclose patient protected health information ("PHI") for the purposes of payment, treatment, and health care operations. However, it has become common practice for conditions such as mental health, HIV/AIDS, substance use, sexually transmitted diseases, and genetic conditions, to necessitate the affirmative permission of a patient — by means of a HIPAA Authorization Form — before diagnostic records and/or other information can be shared with providers and other partners on a patient’s care team. Please keep this in mind as you prepare and present your patient case(s) with close attention to excluding any protected health information.

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