Instructions For Form F-44614i - Aids/hiv Drug Assistance Program And Insurance Assistance Program Application/recertification

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
AIDS/HIV Program
F-44614I (Rev. 02/2017)
1-800-991-5532
Page 1 of 3
INSTRUCTIONS: AIDS/HIV DRUG ASSISTANCE PROGRAM AND
INSURANCE ASSISTANCE PROGRAM APPLICATION/RECERTIFICATION
Individuals enrolled in the AIDS Drug Assistance Program (ADAP) and Insurance Assistance Program (IAP) must
complete recertification every six months to verify ongoing eligibility for the program. Recertification takes place in April
and October of each year.
Completion is voluntary, however to determine eligibility for the ADAP and IAP, all information requested must be
completed. An application will not receive final approval until both parts have been submitted, and approved.
Personally identifiable information collected on the AIDS/HIV Drug Assistance Program and Insurance Assistance
Program Application/Recertification form (F-44614A) will be used in determining a client’s eligibility and may be shared
with Department of Health Services (DHS) staff, client’s pharmacy, physician, case manager, insurance company, and
employer if necessary. This information will be disclosed confidentially to a third party vendor for claims processing and
maintenance purposes. The AIDS/HIV Program will maintain the confidentiality of all information contained on the
Application/Recertification form. Disclosure of your Social Security number is optional and, if provided, may be used by
pharmacists and/or insurance companies to identify clients’ policies and records.
Application Instructions
Application/Recertification includes general information, financial and insurance coverage information and must be
completed and submitted to the AIDS/HIV Program. Be sure to provide all of the information requested in each
section.
In addition to completing the form, you must also provide proof of Wisconsin residency and proof of income.
Part A (F-44614A) is to be completed by the applicant, which requests general, financial, and insurance information.
Part B (F-44614B) is to be completed and signed by the physician the first time an application is submitted to ADAP.
The form is confirmation that the applicant has HIV infection and is or will be prescribed antiretroviral medication within
the next 90 days. The Part B does not need to be completed more than one time.
SECTION I. GENERAL INFORMATION
This section must be filled out completely. Be sure to answer each question. Proof of Wisconsin residency is required.
SECTION II. FINANCIAL INFORMATION
This section applies to you, your parent(s) if you are a minor, and your spouse, if you are married. The information for each
item requested should be completed for all applicable parties and entered on the appropriate line. Include yourself, your
spouse, registered domestic partner, and your legal dependents under family size. Individuals and families above 300%
of the Federal Poverty Level (FPL) will not be eligible for these programs. A table of 2017 income limits is included on
page 2.
The following individuals count towards family size:
 Client
 Client’s spouse (except if legally separated)
 Client’s registered domestic partner
 Client’s children under 18 years of age that the client claims as dependents on their income taxes.
For purposes of ADAP, earned and/or unearned income received by any of the following individuals is counted towards
overall family income:
 Client
 Client’s spouse (unless legally separated)
 Client insured by parents, between 18-26 years old and employed. In this circumstance both the client and parents’
income should be counted towards the family income and both towards family size.
 Client insured by parents, between 18-26 years old and unemployed. In this circumstance the parents’ income
should be counted towards the family income and the family size should be increased to reflect both the parent and
client.
Client’s registered domestic partner, client’s spouse if legally separated, client’s dependent children under 18 years of
age, and parental income does not count for a client over 18 years of age, who is employed, provides their own health
insurance, and lives with parents.

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