Online Referral Form 

PSI is a 501(c)(3) non-profit, charitable organization. For nearly two decades, PSI has helped people who live with certain chronic illnesses or conditions subsidize the cost of health insurance premiums, prescriptions and co-payments. PSI offers services that provide peace of mind to a patient and his/her family to help them afford the medical treatment they need.

How can we help you? 

I’d like to learn more about disease programs PSI funds.

I would you like to apply for assistance. 

PSI evaluates an individual's financial, medical, and insurance situation when determining who is eligible for assistance. If you would like to apply for assistance in a funded program area, please contact us via email or call us toll free at 1-800-366-7741.  A knowledgeable representative would be happy to serve you!  An application for assistance can be mailed directly to you or your physician.

Once completed, you may return the application to: 

Patient Services Incorporated                       OR                Fax it to:   804-744-5407             
PO Box 1602
Midlothian, VA  23113

Once PSI determines my eligibility, when can I expect my treatment assistance to begin?

The issue of assistance with a check payment is usually within 30 days of becoming enrolled in a program. This varies for each program and requires that the receipt of all necessary paperwork (i.e.-insurance papers, completed application, patient consent form, papers regarding treatment costs and/or prescription costs) are provided by the patient and/or his/her physician or insurance company. For more information regarding assistance start times, please contact a customer service representative at 1-800-366-7741 or email your questions to uneedpsi.org.

If I am approved, how long will I be enrolled? 

If approved, assistance will be granted for a maximum of two years pending availability of PSI funding. Should you require assistance beyond the two-year period, you must contact PSI and submit a new application.