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


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

Medical Management

Health Services


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)