HIRSP and HIRSP Federal
Documents and Forms
HIRSP Enrollment HIRSP Federal Enrollment
PDF Icon HIRSP Application for Coverage PDF Icon HIRSP Federal Application for Coverage
PDF Icon Application for Reduced Premium, Deductible, and Drug Out-of-Pocket Maximum. No federal subsidy applicable.
PDF Icon Emergency Application For Reduced Premium, Deductible, And Drug Out-Of-Pocket Maximum No emergency application applicable.

Rate Information

HIRSP Federal Rate Information

PDF Icon HIPAA Privacy Authorization for Use or Disclosure Form

HIRSP Coverage HIRSP Federal Coverage
Pharmacy Information

MedTrak Pharmacy Services

For formulary and pharmacy benefit information please visit the HIRSP Pharmacy Benefit Administrator's site:

>> MedTrak Pharmacy Services

Privacy Forms
PDF Icon HIRSP Notice of Privacy Practices
PDF Icon Your Right to an Independent Review
PDF Icon HIPAA Privacy Authorization for Use or Disclosure Form
PDF Icon HIPAA Privacy Revocation of Authorization Form
PDF Icon HIPAA Privacy Restriction Request Form
PDF Icon HIPAA Privacy Access Request Form
PDF Icon HIPAA Privacy Accounting Request Form
PDF Icon HIPAA Privacy Alternative Communication Request Form
PDF Icon HIPAA Privacy Amendment Request Form
PDF Icon HIPAA Privacy Complaint Form

About Privacy Forms
For agents to inquire on or track the status of an application, the applicant must first complete this authorization form:
HIPAA Privacy Authorization for Use or Disclosure Form
 
Please Note:
HIRSP continues to reimburse agents $40 for providing application materials and assisting HIRSP applicants in filling out the HIRSP Application for Coverage. In order to be reimbursed the agent must complete section 17 of the Application.

Application and Privacy authorization forms should be submitted to:

HIRSP
P.O. Box 8961
Madison,WI 53708-8961