HIRSP Policyholders

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

HIRSP Coverage	HIRSP Federal Coverage
Outline of Coverage Policy for plans HIRSP 1,000; HIRSP 2,500; HIRSP 5,000. Policy for the HIRSP HSA Plan (PDF) Prior-Approval Requirement Prior Approval Request Form Other information about HIRSP is available under Chapter 149, Wis. Stats. Understanding Your Explanation of Benefits Statement: Sample copy with notations explaining benefit information	HIRSP Federal Plan - Outline of Coverage Learn more about hte HIRSP Federal Plan

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
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