| Applications and Enrollment | Download |
|---|---|
| Online Application for Coverage |
Enroll online |
| Application Packet Memo 22333-021-0612 |
 72 KB |
| Application for Coverage (Effective dates January 1, 2008 and later) | 349 KB |
| Application for Reduced Premium, Deductible, and Drug Coinsurance | 170 KB |
| Emergency Application For Reduced Premium, Deductible, And Drug Out-Of-Pocket Maximum | 215 KB |
| Premium Rate Tables effective April 1, 2008 (For questions about claims submission/processing, please call 1-800-828-4777). |
64 KB |
| HIPAA Privacy Authorization for Use or Disclosure Form | 95 KB |
| Coverage and Policy Documents | Download |
|---|---|
| HIRSP Outline of Coverage | 419 KB |
| HIRSP Policy for plans HIRSP 1,000; HIRSP 2,500; HIRSP 5,000. | 146 KB |
| HIRSP Policy: HIRSP HSA Plan | 144 KB |
| Other information about HIRSP is available under Chapter 149, Wis. Stats . | |
| Understanding Your Explanation of Benefits Statement: Sample copy with notations explaining benefit information. 22247-021-0604 |
63 KB |
| Pharmacy Forms | Download |
|---|---|
| Preferred Drug List (Formulary) | Visit Navitus |
| Additional information about formulary (Will link to Pharmacy Benefit Administrator's Web site: Navitus) | Visit Navitus |
| HIRSP Prescription Drug Claim Form | 24 KB |
| Prior Authorization Form for Compounded Drugs | 23 KB |
| Navitus SpecialtyRx Notice | 36 KB |
| Commonly Prescribed Specialty Pharmacy Products | 57 KB |
| What is tablet splitting? |
853 KB |
| HIRSP Expanded Pharmacy Networks | 145 KB |
| Prior Authorization Forms | Download |
|---|---|
| Prior Authorization Forms (Will link to Pharmacy Benefit Administrator's Web site: Navitus) | Visit Navitus |
| Prior Authorization Process (Will link to Pharmacy Benefit Administrator's Web site: Navitus) | Visit Navitus |
| Prior Authorization Form for Compounded Drugs | 23 KB |
| Privacy Forms | Download |
|---|---|
| HIRSP Notice of Privacy Practices | 42 KB |
| Your Right to an Independent Review | 64 KB |
| HIPAA Privacy Authorization for Use or Disclosure Form | 68 KB |
| HIPAA Privacy Revocation of Authorization Form | 62 KB |
| HIPAA Privacy Restriction Request Form | 49 KB |
| HIPAA Privacy Access Request Form | 55 KB |
| HIPAA Privacy Accounting Request Form | 50 KB |
| HIPAA Privacy Alternative Communication Request Form | 54 KB |
| HIPAA Privacy Amendment Request Form | 44 KB |
| HIPAA Privacy Complaint Form | 50 KB |
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 $35 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