Blue Feather

Helpful Documents

  • Form

    Medical Statement Form

    A Medical Care Provider Statement is required for assistance.

  • 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:

    EMAIL
    HIPAAPrivacyOfficer@accessiahealth.org

    MAILING
    Accessia Health: HIPAA Privacy Officer
    PO 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 assistance@accessiahealth.org

  • Form

    Eligibility Reconsideration

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