Helpful Documents 

Form

Medical Statement Form

A Medical Care Provider Statement is required for the following types of assistance:

K

Medical Expenses

K

Copay

K

Premium

K

Travel

Form

Medical Visit Verification Form

A completed Medical Visit Verification Form may be used to provide additional information for a medical visit.

Policies

Patient Policies

Accessia Health’s current Patient Policies are available for review.

Policies

Notice of Privacy Practices

Accessia Health Notice of Privacy Practices is available for review.

Questions or concerns regarding our Notice of Privacy Practices should be directed to our HIPAA Privacy Officer at:

Mailing

Accessia Health: HIPAA Privacy Officer
P.O. Box 5930
Midlothian, VA 23112

Form

W-9 Form

Accessia Health 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.

Email completed Forms

Completed W-9 forms can be emailed to [email protected]

Form

Eligibility Reconsideration

This form is required to request reconsideration of an income decision regarding a patient’s eligibility for assistance.

Contact us

Mailing

Accessia Health
P.O. Box 5930
Midlothian, VA 23112

FAX

(804) 744-9388 Please place your name and phone number on each faxed page.

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