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