HIRSP and HIRSP Federal
Documents and Forms

HIRSP Enrollment	HIRSP Federal Enrollment
HIRSP Application for Coverage	HIRSP Federal Application for Coverage
Application for Reduced Premium, Deductible, and Drug Out-of-Pocket Maximum.	No federal subsidy applicable.
Emergency Application For Reduced Premium, Deductible, And Drug Out-Of-Pocket Maximum	No emergency application applicable.
Rate Information Premium Rate Tables How to read HIRSP Medicare Supplement Rate Tables: 2010	HIRSP Federal Rate Information HIRSP Federal Rate Tables (for effective dates August 1 and after)
HIPAA Privacy Authorization for Use or Disclosure Form

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