Connectors Support Request Form Email Requester Details: Full Name: * HIX Account Email Address: * Phone Number: * Role: * Select From Dropdown New Agent Existing Agent Agency Manager Agency Staff Enrollment Counselor Other License Number: Agency Name or Associated Entity Name: What can we assist with? * Account access issues (DUO, account lockout, account errors, password reset) Book of business transfer (Completed book of business transfer must be attached) Client account escalations (previous request to support and no response within 3 business days required) Request to become a new Agent, Agency Admin Staff or Enrollment Counselor Certification issues/questions DHW questions(PDAP, Idalink, authorized rep., escalations) YHI Agent Line request (YAL) Other Description of Request * Please give a detailed explanation of your request including any steps taken to resolve the issue (If you are receiving a system error, please attach a screenshot of the error you are receiving): Attachments Client Information: First Name: Last Name: Last 4 of SSN: Date of Birth: 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 * Electronic Signature: The information in this section applies to all people signing below, including the Claimant. YHI Privacy Policy *