Current Network Practitioner Forms
Use this form if a new practitioner joins your clinic, leaves your clinic, or has updates to their information.
Use this form if a new facility or location is added, or if a clinic or facility is no longer available to Quartz members.
Print Versions of Online Forms
Health Management Program Referral Forms
(See Resources for Your Patients Section)
For paper submissions only.
This form should be used when submitting a corrected/replacement claim or submitting requested documents (i.e., itemized bills or medical records). A claim should accompany this form. (Download, print, and mail/fax)
This form should be used when there is a request for review of coding-related denial with an explanation of why the provider feels it is coded correctly or when there is a request of Appeal of Coding denial with explanation and supporting documentation. A claim should not accompany this form. If a claim needs to be submitted, then please use the Claim Adjustment Request Form. (Download, print, and mail/fax)