There are program applications that require information from your physician in addition to the online application and household income documentation. If you are applying for assistance for one of the below programs, your physician will need to complete a Medical Care Provider Statement as part of the application process. PSI will send the form to your doctor once the application is received; however, any assistance you can provide in obtaining the form will help expedite your application.

****Medical Care Provider Statement****

Programs that require a Medical Care Provider Statement:

  •  Breast Cancer Screening program
  • Hemophilia Co-pay/Co-insurance Assistance Pilot program
  • Metastatic Renal Cell Carcinoma Incidental Expenses (IE) program
  • Premium assistance programs

This form can be submitted to PSI by:

 FAX:       (804) 744-5407

MAIL:      PSI  PO Box 5930  Midlothian, VA 23112

EMAIL:    [email protected]


PSI Notice of Privacy Practices is available for review.


A detailed understanding of Patient Responsibilities is available for review.