HIRSP Federal Plan
What to Submit

Wisconsin Residency (all applicants)

Attach either a copy of your driver’s license, documentation of voter registration, and/or Wisconsin income tax return.

Citizenship (all applicants)

Attach a copy of one of the following documents

  • WI Driver License
  • WI Identification Card
  • US Passport or US Passport Card
    Permanent Resident Card or Alien registration Receipt Card (Form I-551)
  • Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
  • Employment Authorization Document that contains a photograph (Form I-766)
  • In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien’s nonimmigrant status, as long as the period of endorsement has not yet expired
  • Passport from the Federated states of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form
  • I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

Medical Condition

Attach one of the following documents from an insurer(s) in the past nine months, based wholly or partially on medical underwriting considerations:

  • Notice of rejection of coverage from an insurer
  • Notice of significant reduction in coverage or limitation of coverage, including restrictive riders, due to health reasons
  • Notice of increase in premium of 50%
  • Two or more offers of insurance with premiums at least 50% higher than what you would be charged
    for a standard individual policy with substantially the same coverage and deductibles as the HIRSP Federal Plan.
  • Documentation that you are HIV positive.
    • OR
  • A letter from your physician dated within the last nine months confirming your diagnosis or treatment of one of the conditions listed.

Other Required Information

  • Include separate checks, if applicable, and applications for each applicant.
    • If you have selected Automatic Withdrawal, your premium payments will be automatically deducted from your account either monthly or quarterly depending on your selection.
    • If you have selected Credit Card, your premium payments will be automatically charged to your credit card either monthly or quarterly, depending on your selection.
    • If you have selected Direct Billing, include a check for the full amount of your premium. You will then be billed for your premium payments. You must submit these payments to HIRSP via check or money order.
  • Disclosure Statement–If you wish to authorize HIRSP to release your personal health information, including premium billing or claims billing, to another individual (spouse, other family member, or insurance agent) complete the HIPAA Authorization Form, at the time of your enrollment to avoid service delays or call 1-888-253-2698 to have a form mailed to you.

Mail your completed application, payment (if Direct Bill), and required documentation to: HIRSP at 1751 W Broadway, PO Box 8961, Madison, WI 53708-8961. If you have questions about this application, call HIRSP Federal Plan customer service at 1-888-253-2698
or 1-608-221-5315.

Failure to comply with all application requirements may delay the effective date for your coverage under the HIRSP policy.