Quartz Medicare Advantage Members Forms & Resources
Forms and resources for your Quartz Medicare Advantage (HMO) plans
Enrollment
To access the Quartz Medicare Advantage enrollment application, please visit the enrollment page.
2026 Plan benefit selection forms
To change plans, please complete the following form:
- Gundersen Quartz Medicare Advantage plan:
Regular print | Large print - Gundersen MN Quartz Medicare Advantage plan:
Regular print | Large print - UW Health Quartz Medicare Advantage plan:
- Online plan benefit selection form tool
2027 Plan benefit selection forms
To change plans, please complete the following form:
- Gundersen Quartz Medicare Advantage plan:
Regular print | Large print - Gundersen MN Quartz Medicare Advantage plan:
Regular print | Large print - UW Health Quartz Medicare Advantage plan:
Other forms
- Appointment of Representative form – If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal, or grievance, please use this form.
- Delta Dental Certificate of Coverage
- Supplemental dental disenrollment form
- Determination of benefits worksheet
- Member CashCard reimbursement form – For fitness membership and medical rides (for eligible plans)
- Member dental claim form
- Member medical claim form
- Part D prescription drug reimbursement form
- Premium payment option form
- Sign up for Auto-pay
Submitting forms
Completed forms can be mailed or faxed to:
Quartz Medicare Advantage (HMO)
2650 Novation Parkway
Fitchburg, WI 53713
Fax: (608) 881-8396
Protected Health Information (PHI) Authorization
You have the right to allow someone else to access your Protected Health Information (PHI). To do so, please complete and submit the Authorization for Disclosure of Protected Health Information form at QuartzBenefits.com/PHIform or in Quartz MyChart.
You may also print and mail the Authorization to Disclosure of Protected Health Information form and send it to Quartz.
Appeals & Grievances
You or your authorized representative may request an initial decision or appeal.
Your prescriber or treating provider may also request it for you.
We are here for you.
If you have questions or need support, your local Quartz Champion is here for you.
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