Individual & Family Plan Members
Forms + Resources
Individual & Family plan forms and resources
Thank you for choosing Quartz! We want to make it easy for you to use your health plan. To help you, we’ve gathered some helpful resources to walk you through important details.
How to keep your information updated
Need to make changes to your plan election, name, address, telephone number, or email address? Here’s how:
Members in Wisconsin and Illinois
- Log in to your account at QuartzBenefits.com/marketplace
- Call Quartz Customer Success at (800) 362-3310
Members in Minnesota
- Log in to your account at MNsure.org
- Contact MNsure at (651) 539-2099 or (855) 366-7873
Questions? We’re here to help. Call Customer Success at (800) 362-3310.
Access the forms you need.
Get secure and convenient access to member forms and resources through Quartz MyChart.
- Send a Secure Message
- Change Your Primary care provider (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
Get an Answer Online — Right now!
- Find a Doctor
- Health Topics
- Summary of Benefits and Coverage Lookup
- Transparency in Coverage
- Wisconsin PricePoint Tool – Get basic, facility-specific information about health care services and charges
- HSA Bank’s Calculator Tool
Forms
- Appointment of Representative for Appeal Form (PDF)
- Determination of Benefits Worksheet (PDF)
- Drug Formulary (choose your formulary, then download the document)
- Authorization for Disclosure of Protected Health Information Form
- Member Reimbursement Form (PDF) (direct member reimbursement form for medications)
- Member Claim Form (PDF) (for health care other than medications)
- Recurring payment option
Essential Information and Resources
- Pharmacy Information and Prior Authorization
- Preventive services covered under the Affordable Care Act – Wisconsin | Illinois
- Contraceptive services covered under the Affordable Care Act
- View the most recent issue of the Member Newsletter
- View Your Rights and Protections Against Surprise Medical Bills
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 Release 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.
Contact us
We’re here to help you find the right plan option that works for you and your family. Please contact Quartz Customer Success at (800) 362-3310, or if you have worked with an agent in the past, reach out to them with any questions on your 2024 Quartz plan options.