Billing/Financial Support Services

Fusion Health Services is committed to maintaining the strict confidentiality of your Protected Health Information (PHI). We comply with the Health Insurance Portability and Accountability Act (HIPAA), the HITECH Act, and the Omnibus Rule.

We use and disclose PHI strictly for:

Treatment: Sharing medical details with providers involved in your care.
Payment: Coordinating with insurance carriers for claims and eligibility.
Operations: Managing internal quality and administrative functions.

We maintain physical, technical, and administrative safeguards to protect your data.

For complete HIPPA Compliance Statement:

https://d7da7ca5-aef0-4b1e-8689-d09dfc40160d.usrfiles.com/ugd/d7da7c_65746e5c91624125875185836b7d13a4.pdf

First Name

Last Name

Birthday

Month

Day

Year

Cell Phone Number

Health Insurance?

Yes

Other

Insurance company name

Insurance Member ID

Upload Insurance Card

Upload your file

Choose a file or drag and drop one here.

Secondary Insurance?

Yes

Insurance Company Name

Insurance Member ID

Secondary Insurance Card

Upload your file

Choose a file or drag and drop one here.

Date of Service in Question

Month

Day

Year

Do you have an EOB, insurance letter, or other document that would help us review the issue?

Yes

Other

File upload

Upload your file

Choose a file or drag and drop one here.

Additional information

I understand that this form is for billing questions only. It should not be used for medical questions, prescription requests, appointments, medical records, or urgent medical concerns.

I understand that billing inquiries are answered within 5–7 business days through Tebra Patient Portal messaging, and I am responsible for ensuring I have access to my patient portal.

Signature

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We use and disclose PHI strictly for:

Treatment: Sharing medical details with providers involved in your care.
Payment: Coordinating with insurance carriers for claims and eligibility.
Operations: Managing internal quality and administrative functions.

We maintain physical, technical, and administrative safeguards to protect your data.

For complete HIPPA Compliance Statement:

https://d7da7ca5-aef0-4b1e-8689-d09dfc40160d.usrfiles.com/ugd/d7da7c_65746e5c91624125875185836b7d13a4.pdf

Birthday

Month

Day

Year

Health Insurance?

Yes

Other

Insurance company name

Upload Insurance Card

Upload your file

Choose a file or drag and drop one here.

Secondary Insurance?

Yes

Insurance Company Name

Secondary Insurance Card

Upload your file

Choose a file or drag and drop one here.

Date of Service in Question

Month

Day

Year

Do you have an EOB, insurance letter, or other document that would help us review the issue?

Yes

Other

File upload

Upload your file

Choose a file or drag and drop one here.

Additional information

I understand that this form is for billing questions only. It should not be used for medical questions, prescription requests, appointments, medical records, or urgent medical concerns.

I understand that billing inquiries are answered within 5–7 business days through Tebra Patient Portal messaging, and I am responsible for ensuring I have access to my patient portal.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.