Form F-44614a - Aids Drug Assistance Program And Insurance Assistance Application - 2017 Page 3
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3F-44614A (Rev. 02/2017)
Page 3 of 3
SECTION III. INSURANCE INFORMATION
Check all boxes that describe your health insurance status. At least one box must be checked.
No health insurance of any kind
Medicaid coverage (Medicaid, Title 19, MA)
BadgerCare Standard Plan (BCSP)
Have you applied for BCSP in the last 30 days?
Yes
No
Medicaid Purchase Plan (MAPP)
Medicare coverage (Part A/B)
Medicare Part D (Prescription Drug Coverage)
Medicare supplement insurance – Basic Plan
An individual insurance policy – Silver Plan through the Marketplace
A group insurance policy provided by an employer
COBRA or similar continuation coverage
Individual policy purchased outside of the Marketplace
Other_____________________________________________________________________________________________
Premium Payment Information (
If applying for the Insurance Assistance Program, complete this section)
Name of Company the premium check will be made out to:
Address where premium should be sent
Name and Telephone number of contact person receiving premium
Regular Premium amount
Next Payment Due
Premium is paid
Monthly
Quarterly
AIDS/HIV DRUG ASSISTANCE AND INSURANCE ASSISTANCE PROGRAMS
AUTHORIZATION TO RELEASE INFORMATION
I authorize the Wisconsin Department of Health Services (DHS) to receive and disclose medical information related to my HIV status to
DHS staff, my designated pharmacy, my physician, my case manager, my private insurance company and/or my employer as needed to
determine and maintain my eligibility for benefits under the Wisconsin AIDS/HIV Drug Assistance Program and/or Insurance Assistance
Program and to administer these programs. I understand that this information will be disclosed confidentially to a third party vendor for
claims processing and/or insurance premium payments and administrative purposes.
I hereby certify that all the information I have provided in this application/recertification is true and complete. I understand that I am
subject to termination of my enrollment eligibility and possible prosecution under state and federal laws if this information is false.
SIGNATURE of Applicant or Guardian
Date Signed
Print Name of Applicant or Guardian
Division of Public Health
Return the completed Application/Recertification,
Attn: ADAP
income, and residency verification in an envelope
PO Box 2659
marked “CONFIDENTIAL” to:
Madison, WI 53701-2659
Or
Fax to: (608) 266-1288
Reset/Clear form
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