How to apply

Application Information

This section of the HIRSP Web site offers connections to important application forms and instructions on how to complete them. The forms are in PDF format for ease of printing, we also provide an Online Application.

Individuals who want to apply for HIRSP coverage or for reductions in premium, deductible, and drug coinsurance out-of-pocket maximum may fill out these forms and submit them to HIRSP.

Save Time

If you qualify for BadgerCare Plus or Medicaid, you will be ineligible for HIRSP.
To save time, see if you qualify for Medicaid or BadgerCare Plus before applying for HIRSP.

• Online Application for Coverage
  
• View the application for effective dates January 1, 2008 and later
• Application for Reduced Premium, Deductible, and Drug Coinsurance
  
• Emergency Application for Reduced Premium, Deductible, and Drug Coinsurance
  
• HIPAA Privacy Authorization for Use or Disclosure Form

Mail your completed application, payment, and relevant documentation to:

HIRSP
1751 W Broadway
PO Box 8961, Madison, WI 53708-8961

If you have questions about your application call HIRSP customer service at 1-800-828-4777 or 1-608-221-4551.