Medical Statement Form
A Medical Care Provider Statement is required for the following types of assistance:
- Medical Expenses
Medical Visit Verification Form
A completed Medical Visit Verification Form may be used to provide additional information for a medical visit.
Accessia Health’s current Patient Policies are available for review.
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:
Accessia Health: HIPAA Privacy Officer
P.O. Box 5930
Midlothian, VA 23112
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 firstname.lastname@example.org
This form is required to request reconsideration of an income decision regarding a patient’s eligibility for assistance.