Form F-44614a - Aids Drug Assistance Program And Insurance Assistance Application - 2017
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1
2
3DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
AIDS/HIV Program
F-44614A (Rev. 02/2017)
1-800-991-5532
Page 1 of 3
AIDS/HIV DRUG ASSISTANCE PROGRAM AND INSURANCE ASSISTANCE PROGRAM
APPLICATION/RECERTIFICATION – Part A
Check the program(s) for which you are applying:
Drug Assistance Program
Insurance Assistance Program
SECTION I. GENERAL INFORMATION
Last Name
First Name
Middle Initial
Date of Birth
Social Security Number (Disclosure of your Social Security number
(SSN) is voluntary, however most insurers and pharmacies use the SSN
-
-
to identify policies and records. Supplying your SSN will expedite
verification of insurance coverage and the processing of this
Application/Recertification)
Contact Information
Street Address
Apt/Unit No.
Mailing Address (if different)
Apt/Unit No.
City
County
State
Zip
City
County
State
Zip
Home Telephone Number
Alternate/Cell Telephone Number
OK to leave message saying caller is from the Drug Assistance
OK to leave message saying caller is from the Drug Assistance
Program or Insurance Assistance Program?
Yes
No
Program or Insurance Assistance Program?
Yes
No
Gender
Marital Status
Race/Ethnicity (check all that apply)
Male
Never Married
Caucasian (White)
Native Hawaiian/Pacific
Non-Hispanic
Female
Married
Islander
African American
Hispanic
Transgender
Registered Domestic
(Black)
Native Hawaiian
Mexican, Mexican
(Male to Female)
Partnership
American, or
Guamanian or
Asian
Transgender
Living with a Partner
Chicano/a
Chamorro
(Female to Male)
Asian Indian
Divorced
Puerto Rican
Samoan
Unknown
Chinese
Separated (legally)
Cuban
Other Pacific
Filipino
Islander
Widowed
Another Hispanic,
Japanese
Latino/a, or
_________________
Spanish Origin
Veterans Status
Korean
Preferred Language
Other
Vietnamese
American Indian/
_____________
Veteran
English
Alaskan Native
Other Asian
Not a Veteran
Spanish
Unknown
Other – specify:
Other – specify:
_____________
_________________
_________________
Residency
Case Management (if applicable)
(Attach supporting documentation)
Case Manager and Agency
Resident of Wisconsin
Not a resident of Wisconsin
Employment Status
(Check which best describes your current employment status)
Employed Full-time
Employed Part-time
Unemployed
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