Access the Forms You Need
Get secure and convenient access to member forms and resources through MyChart.
- Send a Secure Message
- Change Your Address
- Change Your Primary Care Physician (PCP)
- Determination of Benefits Form
Use this form to help determine costs you may incur prior to receiving health care services. To complete the form, you will have to ask your provider for certain medical coding information, including procedure codes, procedure modifiers, and unit codes for the services.
- Health Risk Assessment (HRA) on the Quartz Well Portal
- Order or Print an ID Card
- Order Printed Materials
- Other Insurance Questionnaire
You can also contact Quartz Customer Service at (800) 362-3310.
Printed materials you can request include:
- Provider Directory
- Member Guide
- Certificate of Coverage
- Prescription Drug Benefit Brochure
- Preventive Services Covered Under the Affordable Care Act
- Prescription Drug Formulary
- Notice of Privacy Practices
- Determination of Benefits Worksheet (PDF)
- Drug Formulary (choose your formulary, then download the document)
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Authorized Representative for Appeal Form (PDF)
- Health Plan Transition Form (PDF)
- Member Reimbursement Form (PDF) (direct member Reimbursement Form for medications)
- Member Claim Form (PDF) (for health care other than medications)
- Member Claim Form (PDF) (for at-home COVID-19 test)
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.