Choose font size
Want to submit prior authorizations electronically? Quartz accepts initial prior authorization requests via the provider portal, My Quartz Tools. Log in to My Quartz Tools and refer to the User Guide for details on the process.
Medication Prior Authorization
Medical (General) Prior Authorization
Behavioral Health Prior Authorization

Please select the appropriate prior authorization request form below and submit to:

Quartz Behavioral Health Care Management

  • Fax (608) 471-4391

Submission instructions are included with all forms.

Initial Mental Health Request Form

AODA Initial Request Form

  • Do not use these forms to request PA for TMS. 
  • A prior authorization (PA) is only required for outpatients if the request is for services with an out-of-network provider.

Mental Health Treatment Extension Request

AODA Extension Request Form

  • Use these forms to request an extension of a previously approved request.

Transcranial Magnetic Stimulation (TMS) Request Form
  • This form is used without the Initial Mental Health Treatment Request 
Eating Disorder Supplemental Request Form
  • This form is used in addition to the Initial Mental Health Treatment Request or the Extension Mental Health Treatment Request form.

For self-funded participants, please log in to My Quartz Tools to access your patient's PA List.