Required fields are indicated by a highlight.

1. 
   
   

   1. Please enter your contact information.

2. User ID   (?)  I don't know my User ID.
3. TIN/NPI
4. Contact Name   First and Last Name
5. Email
6. Phone
7. 
   
   

   2. Select the HealthFusion Solution that most pertains to your case.

8. Case Reason -- Please Select -- Enrollments MediTouch EHR Practice Management Clearinghouse ERA Only Mobile Applications Miscellaneous
9. Enrollments Detail -- Please Select -- Claims Real-Time Electronic EOB / ERA
10. MediTouch EHR Details -- Please Select -- Setup / Implementation Patient Upload / Registration Meaningful Use Question Dashboard Encounters Patient Charts e-Prescribe Orders Document Management Patient Health Records / PHR Other Issue
11. PM System Detail --None-- Setup Patient Upload / Registration Patient Demographics Scheduling Claims Real-Time ERA Denial Management Secondary Billing Accounts Receivable / AR Payments Statements Reporting Other Issue
12. Clearinghouse Detail -- Please Select -- Setup Mapping Patient Upload / Registration Claims Bulk Submission Claim File Upload Secondary Claims Real-Time ERA Reporting PQRI Other Issue
13. Claim ID
14. RT Trans ID
15. ERA Check ID
16. Claim ID
17. RT Trans ID
18. ERA Check ID
19. ERA Only Detail -- Please Select -- Account Setup EFT with no Matching ERA Forgot Password Log In Problem Missing ERA Need Training Page Display Issue Payer Registration Issue Provider Setup Registration Question Other
20. ERA Check ID
21. Miscellaneous Detail -- Please Select -- Broken Page / Page Display Issue AOA/AOIA-Related Issue or Question Feature Request Forgot Password Login Issue Partner Question Other Issue
22. 
    
    

    3. Enter a subject and a case description. Please submit when finished.

23. Case Subject
24. Case Description Please enter a case description (no Patients' Protected Health Information or PHI, please).
25.