Diabetes ECHO Application

The application period for the 2023 Diabetes ECHO Cohort is open.

2023 Diabetes ECHO Application Opens November 7, 2022

Diabetes ECHO Registration

Thank you for your interest in participating in Well-Ahead Louisiana’s Diabetes ECHO. The application period for the 2023 Diabetes ECHO Cohort is open from November 7, 2022 through December 9, 2022. Click here to view the Diabetes ECHO webpage and learn more about the Diabetes ECHO.

Please complete the application below to enroll your facility in the 2023 Diabetes ECHO. Applications must be submitted by Friday, December 9, 2022. A Diabetes ECHO staff member will reach out with more information by Friday, December 16, 2022. One application should be submitted per clinic, to include all anticipated participants from the facility.

Primary Contact

Name(Required)

First Last

Credentials(Required)

Title(Required)

Email(Required)

Number(Required)

Healthcare Site Information

Clinic Name(Required)

Clinic Parish(Required)

Clinic Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Total Number of Clinic Health Providers at this Site(Required)

Which of the following best describes your healthcare site?(Required)

Clinic Signature Authority (Individual Signing the MOU)

Name(Required)

First Last

Credentials(Required)

Title(Required)

I would like to register another participant from my facility.(Required)

Yes

Additional Participant(s) Information

For each additional participant, please include their full name, email address, title, clinical credentials and current role.

I understand that participating clinics/providers must agree to the following:(Required)

At least one participant from the facility must be present at least 50% of the sessions (approximately two sessions per month from January-September). At least one participant from the facility must submit and present at least one patient case during the calendar year. All participants must complete two surveys (pre and post survey) to assess efficacy of the program. Participants who wish to receive CEUs must also complete a brief post-session survey for each session attended.

I agree.

Name

This field is for validation purposes and should be left unchanged.