General
Employee Enrollment Form
Employee Enrollment Form (Spanish)
Emergency and Out of Area Care
Large Group Risk Evaluation
Large Group Application
How We Evaluate New Technology
New Telemed Provider Broker Letter
New Telemed Provider Employer Letter
Member Appeal Form
Vision Reimbursement Claim Form
Vision and Dental Enrollment Form
Legal & Policy
California Consumer Privacy Act Opt Out Form
Continuity of Care Form
MotivHealth Insurance Privacy Policy
Member Rights and Responsibilities
Request Accounting PHI Disclosures
Request to Amend PHI Form
Surprise Billing Model Notice
Creditable Coverage Disclosure Notice
Transparency in Coverage Notice
Disability Form
Authorization Disclose PHI
HSA & Investments
ABG Advisory Agreement
Beneficiary Designation
Contribution Form
Distribution Excess HSA Contributions
Electronic Transfer of Funds
HSA Letter of Medical Necessity
Instructions Upon Death
MotivHSA Employee Contribution Election
Employer HSA Contribution Upload
HSA Partial Transfer Out Request Form
HSA Direct Deposit Instructions
HSA EFT Wire Instructions
HSA Closure Form
Instructions Upon Divorce
Mistaken Distribution
Partial Transfer Request
HSA Reimbursement Form
Return Mistaken Contribution
Rollover Request
Transfer Request
Transfer Request (Spanish)
Employer HSA Contribution Correction
MotivHSA Mutual Funds List
MotivHSA Fee Schedule
Cash Interest Rate Schedule
HSA Change of Personal Information Form
MotivHealth Insurance Company
844-234-4472 | MEDICAL
385-247-1030 | PHARMACY
385-308-4400 | EMPLOYERS
385-308-4410 | MOTIVNET – Contract
10421 S Jordan Gateway, Ste. 300
South Jordan, UT 84095
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