Support Request

Get help with your account, enrollment, or coverage questions.

Special Enrollment Period question?

If your support request is related to a Qualifying Life Event/Special Enrollment Period, click here for more information: Your Health Idaho Special Enrollment.

(* Required field)

Primary Account Holder's Name *

First

Middle

Last

Phone Number *

Email Address *

Last 4 digits of SSN *

Date of Birth *

Are you working with a Your Health Idaho-Certified Agent, Broker or Enrollment Counselor? Or are you a Certified Partner yourself and submitting this information on behalf of your client?

If yes, please provide the following information:

Name

Role

Phone Number

Agency

If your support request is related to a Qualifying Life Event/Special Enrollment Period, please visit Your Health Idaho Special Enrollment for more information:

Please select the category that best reflects your issue:

Please give a detailed explanation of your request.

Verification documents may be requested after enrollment is approved. Failure to provide verification may impact your APTC determination.

Support Request *

Supporting Documentation

Drag & Drop Files, Choose Files to Upload

Supporting Documentation

Drag & Drop Files, Choose Files to Upload

Supporting Documentation

Drag & Drop Files, Choose Files to Upload

Notice of Privacy Practices

Your Health Idaho is committed to maintaining the privacy and security of personally identifiable information. Your Health Idaho will use personally identifiable information only as permitted by Your Health Idaho's policies and as required by law.

More information about Your Health Idaho's privacy and security practices and your rights is available on Your Health Idaho's website at YHI Privacy Policy

If you need help understanding this form in another language, or if you are disabled and need help to use this form, please contact Your Health Idaho. There is no cost for assistance.

Read and Sign Below - Electronic Consent

Full Name *

Agency Birth Address

Electronic Signature *

The information in this section applies to all people signing, including the Claimant. I further understand that by completing, signing, and dating, I authorize Your Health Idaho to disclose information collected based on my application and from other data sources that may have been used to make the eligibility determination. I understand that this information may be disclosed for use during the appeals process. I understand by completing, signing, and dating, I authorize Your Health Idaho to disclose information in my eligibility record, based on the application I filled out, and from other data sources that may have been used to make the eligibility determination, to my authorized representative and other household members whose signatures are provided. I am signing this form under penalty of perjury, which means I have provided true answers to all the questions I have answered to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I provide false information. I understand that I am not required to complete this form. By pressing "Submit", you are providing consent to submit your Personally Identifiable Information. YHI Privacy Policy

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Support Request

Special Enrollment Period question?

Are you working with a Your Health Idaho-Certified Agent, Broker or Enrollment Counselor? Or are you a Certified Partner yourself and submitting this information on behalf of your client?

If your support request is related to a Qualifying Life Event/Special Enrollment Period, please visit Your Health Idaho Special Enrollment for more information:

Please give a detailed explanation of your request.

Verification documents may be requested after enrollment is approved. Failure to provide verification may impact your APTC determination.

Notice of Privacy Practices

Read and Sign Below - Electronic Consent

A copy of this Support Request will be emailed to you and any designated authorized representatives.

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