Medical Statement Form
A Medical Care Provider Statement is required for the following types of assistance:
Infusion and Nursing Services
Medical Visit Verification Form
A completed Medical Visit Verification Form may be used to provide additional information for a medical visit.
PSI’s current Patient Policies 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:
PSI: HIPAA Privacy Officer
P.O. Box 5930
Midlothian, VA 23112
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.