Eligibility Support Form

Are you working with a YHI-certified Consumer Connector (or are you a Consumer Connector yourself)?

If yes, please provide the following 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

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

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