Wisconsin - Forms | Quartz

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Large Group Product Forms

Large Group Product Forms

New Large Group Forms	Existing Large Group Forms
Employer Group Application	Employee Application for New Hire
Employee Application Form — English \| Spanish (Use when no claims experience)	Waiver of Coverage Form — English \| Spanish
Employee Application Form — English \| Spanish (Use with claims experience)	COBRA Group Continuation Notice
New Group Checklist - Large Group Submitting Experience Data New Group Checklist - Large Group Submitting Health Applications	Quartz Drug Formulary: $0 Copay List
Large Group Census Template	Quartz Drug Formulary: RX Outcomes List
Creditable Coverage – 2020 \| Learn More	Quartz High-Deductible Health Plan $0 Safe Harbor Drug List

Small Group Product Forms

Small Group Product Forms

New Small Group Forms	Existing Group Forms
Small Group Enrollment Kit	2019 Benefit Overviews
Small Group Employee Application	CMS Survey
Small Group ACA Plans - 2019 \| 2020	New Hire Application / Change Form
Small Group Census Template	COBRA Group Continuation Notice
	Creditable Coverage - 2019 \| 2020 \| Learn more
	Creditable Coverage - Transitional Plans
	Small Group Transitional / KYP Plans
	Small Group Underwriting Reference Guide
	Quartz Drug Formulary: $0 Copay List
	Quartz Drug Formulary: RX Outcomes List
	Quartz High-Deductible Health Plan $0 Safe Harbor Drug List

Individual & Family Forms

Individual & Family Forms

2020

Individual Application	Individual Plan Options
English	Quartz One - Standard Plans \| CSR Plans
Spanish	Quartz Prime - Standard Plans \| CSR Plans
	Beloit One - Standard Plans \| CSR Plans

Recurring Payment Authorization Form

Medicare Forms

Medicare Forms

Medicare Select Forms	Senior Choice Forms
Medicare Select Provider Directory	5 Reasons to Choose Senior Choice
Medicare Select Application	Senior Choice Application
Medicare Select Outline of Coverage	Senior Choice Outline of Coverage
Wisconsin Guide to Health Insurance for People with Medicare	Senior Choice Replacement Form
	Senior Choice MyChart Flyer
	Senior Choice Rider Change Form

Miscellaneous Forms

Miscellaneous Forms

Authorization for Disclosure of Protected Health Information

Health Care Transition Form

Spanish Materials

Spanish Materials / Materiales en Español

Notice of Privacy Practices - Spanish	Balance Billing- Spanish
Find a Doctor - Spanish	HRA - Spanish
MyChart - Spanish	Preventive Care Services - Spanish
Quartz Well - Spanish	Prospective Member Brochure - Spanish