Eligibility Support Form

The information in this section applies to all people signing below, including the Claimant. I further understand that by completing, signing, and dating below, 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 below, 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 below. 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 "Send Message", you are providing consent to submit your Personally Identifiable Information (PII).