Medical Statement Form
A completed Medical Care Provider Statement is required for the following PSI programs:
- Ancillary assistance programs
- Breast Cancer Screening program
- Premium assistance programs
- Travel assistance programs
Medical Visit Reimbursement Form
A completed Medical Visit Reimbursement Form can be used for proof of a medical visit/treatment and/or transportation for reimbursement purposes if applicable to your assistance.
PSI's current Patient Responsibilities are available for review.
PSI Notice of Privacy Practices
PSI Notice of Privacy Practices is available for review. Questions or concerns regarding our Notice of Privacy Practices should be directed to PSI's HIPAA Privacy Officer at [email protected] or P.O. Box 5930, Midlothian, Virginia 23112-0033.
PSI is required by the IRS to obtain a W-9 form from all physicians, hospitals, treatment centers, infusion pharmacies, and insurance third party administrators (COBRAs) to which we provide payment. The completed W-9 must be on file prior to releasing any payments. A blank W-9 and instructions are available for download and can be emailed directly to [email protected].
Reach us at
- EMAIL: [email protected]
PO Box 5930
Midlothian, VA 23112
- FAX: (804) 744-5407
Please place your name and phone number on each faxed page.