Provider Forms

Our Online Forms make it easy to fill out and submit forms.

Become a Quartz Provider

Access Provider Participation Request Form

MyPlanTools

Access Request Form

New Practitioner Form

Practitioner Change Form

Practitioner Termination Form

New Location Form

Location Termination Form

The forms below offer print versions of the online forms and access to other Quartz forms.

Medical Management

General Prior Authorization Request Form (download, print & mail / fax)

Health Services

Health Management Program Referral Forms (See Resources for Your Patients) section

Claims

Claim Adjustment Request Form

This form should be used when submitting a corrected/replacement claim or when submitting requested documents (i.e. itemized bills or medical records). A claim should accompany this form.(download, print & mail / fax)

Coding Denial Appeal Form

This form should be used when there is a request for review of coding related denial with an explanation of why provider feels it is coded correctly or when there is a request of Appeal of Coding denial with explanation & 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 & mail / fax)