Complex Case Management Request Form

Using this form does not replace medical care. If you are having a medical emergency, dial 911.

Complex Case Management

The coordination of care, services and resources for members who have complex medical and social needs by:

  • Providing education about your health condition and care
  • Supporting and reinforcing treatments and therapies recommended by your health care provider
  • Coordinating health services and clarifying insurance benefits
  • Connecting you to community services or programs, if eligible

If you are interested in learning more about complex case management, call the Quartz Complex Case Management Program at (866) 884-4601 or sign up below.

Complex Case Management Request Form

Member Name
Member Address
MM slash DD slash YYYY
What Would You Like to Do?
Would You Like a Call Back?

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