Appeals Form

Please keep a copy of all forms for your records

Instructions

You have thirty (30) days from the date YHI or the Idaho Department of Health and Welfare (IDHW) mailed or emailed your Eligibility Notice to file an appeal. The date of the postmark on your appeal envelope, the date of your phone call request, or the date your email is received is considered the date you filed your appeal..

To File an Appeal:

1. Complete the electronic Appeal Request Form.
2. Submit the form to YHI with any contact method described in “YHI Contact Information.”

First Name

Middle Name

Last Name

Date of Birth

Email Address

Phone Number

Street Address

Apt. / Ste. #

City

State

Zip Code

Type of Appeal

Your Eligibility Notice explains whether you qualify to purchase insurance on YHI. Depending on your eligibility results,
you may appeal for any of the following reasons (check as many boxes as you would like).

My appeal is because my eligibility to purchase or use health insurance on the exchange was denied for the following
reason(s) on the following date(s):

Eligibility Type

Enrollment Eligibility

Date of Denial or Notice

Special Enrollment Period

Date of Denial or Notice

Change of effective or termination date

Date of Denial or Notice

Application of APTC/CSR

Date of Denial or Notice

APTC Eligibility

Date of Denial or Notice

CSR Eligibility

Date of Denial or Notice

Other

Date of Denial or Notice

Explain the reason for your appeal

Your explanation should state the reason for your appeal, including relevant dates and account history.
List any actions or communications you attempted to resolve your request prior to the appeal.

If your appeal request affects or impacts other members of your household, note their names and how they are
impacted here. Add additional pages if needed.

Explanation of Appeal Request:

Supporting Documentation for Consideration

Do you need assistance completing this appeals request?

You may appoint an authorized representative.

You can give a trusted person permission to communicate about this appeal with us, see your information, and act for
you on matters related to this appeal, including getting information about your appeal and signing your appeal on your
behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative,
contact YHI.

Name

Role

Phone Number

Email Address

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

Appeals Form

**Please keep a copy of all forms for your records**

Instructions

To File an Appeal:

Type of Appeal

Eligibility Type

Explain the reason for your appeal

Do you need assistance completing this appeals request?

You may appoint an authorized representative.

Notice of Privacy Practices

Read and Sign Below - Electronic Consent

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

Please keep a copy of all forms for your records