Get Appeals Request Form - Your Health Idaho

Filing an appeal can be an important step if you believe there's been a mistake regarding your eligibility for health insurance through Your Health Idaho. This guide provides clear, step-by-step instructions on how to complete the Appeals Request Form online to ensure that your appeal is properly submitted.

Follow the steps to accurately complete your Appeals Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin filling out the 'Claimant 1' section. Include their first name, middle name, last name, date of birth, suffix, phone number, email address, street address, city, apartment or suite number, state, and ZIP code.
3. List the names of other household members who are also filing an appeal, using additional paper if necessary.
4. Indicate the type of appeal by checking the appropriate boxes based on your eligibility notice.
5. Provide the date of your eligibility notice as indicated in the upper right corner of the notice.
6. Fill out the appeals hearing request section if you wish to have your appeal heard by the Governance Committee.
7. Explain the reason for your appeal in the designated section, detailing why you believe a mistake was made.
8. If assistance is needed, provide the name and contact information of your authorized representative.
9. Each adult in the household must sign to authorize the disclosure of their information. This includes the claimants and any other adults in the household.
10. Review all sections for accuracy. Save your changes, and choose to download, print, or share the form as required.

Complete your Appeals Request Form online today to ensure your voice is heard in the eligibility determination process.