Instructions For Form F-44614i - Aids/hiv Drug Assistance Program And Insurance Assistance Program Application/recertification Page 3
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3F-44614I (02/2017)
Page 3 of 3
If you are staying with friends or family, you may provide:
▪
A letter stating this from the friend or family member which includes the home’s address
▪
Written statement from your case manager indicating they have conducted a home visit at the current address
Authorization to Release Information/Authenticity Statement
You, a legal guardian, or Power of Attorney completing the Application/Recertification must sign and date the
Application/Recertification indicating that the Authorization Statement has been read in full and will be complied with.
Authorization will be valid for one year after the application is signed.
ADAP Approval of Applications
Written notification of Application/Recertification approval or denial will be mailed to the client’s mailing address provided
in the General Information Section and the pharmacy address provided in the Pharmacy Information Section.
Insurance Assistance Program Approval of Applications
Once a completed Application/Recertification is approved, the AIDS/HIV Program will arrange to pay for client’s health
insurance premiums. Written notification of Application/Recertification approval or termination will be mailed to the client’s
mailing address provided in the General Information Section.
Assistance Completing the Application/Recertification
If you have questions about the information requested in this Application/Recertification call the AIDS/HIV Program at
(800) 991-5532. For assistance in completing this Application/Recertification, you may contact an AIDS/HIV case
manager at one of the following organizations in your area:
City
Agency
Phone Number
Appleton
AIDS Resource Center of WI (ARCW)
920-733-2068
Beloit
AIDS Resource Center of WI (ARCW)
608-364-4027
Beloit Area Community Health
608-361-0311
Eau Claire
AIDS Resource Center of WI (ARCW)
800-750-2437
Green Bay
AIDS Resource Center of WI (ARCW)
800-675-9400
Kenosha
AIDS Resource Center of WI (ARCW)
800-924-6601
La Crosse
AIDS Resource Center of WI (ARCW)
800-947-3353
Madison
AIDS Resource Center of WI (ARCW)
608-316-8600
UW HIV Comprehensive Care Program
608-263-0946
Milwaukee
AIDS Resource Center of WI (ARCW)
800-359-9272
Froedtert Medical College Clinic
414-805-6444
Sixteenth Street Community Health Center
414-672-1353
Milwaukee Health Services
414-372-8080
Superior
AIDS Resource Center of WI (ARCW)
877-242-0282
Wausau/Schofield
AIDS Resource Center of WI (ARCW)
800-551-3311
Return your completed Application/Recertification, income, and residency verification in an envelope marked
“CONFIDENTIAL” to:
Division of Public Health
Attn: ADAP
P.O. Box 2659
Madison, WI 53701-2659
Or fax to (608) 266-1288
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