Medical Statement Form
A completed Medical Care Provider Statement is required for the following PSI programs:
- Ancillary assistance programs
- Infusion and Nursing Services assistance programs
- Premium assistance programs
- Travel assistance programs
Medical Visit Verification Form
A completed Medical Visit Verification 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].
PSI Emergency Assistance Attestation
A signed PSI Emergency Assistance Attestation is required in order to apply for the PSI Emergency Assistance Fund. This Fund is for active PSI patients who have been diagnosed with COVID-19, have a household member who has been diagnosed with COVID-19, or have suffered a job loss or job reduction, or the primary wage earner in the family unit has suffered job loss or job reduction as a result of COVID-19.
Reach us at:
P.O. Box 5930
Midlothian, VA 23112
EMAIL: [email protected]
FAX: (804) 744-5407 Please place your name and phone number on each faxed page.