Provider Forms

Current Network Practitioner Forms

Forms are required for contracted providers when there is a change within their facility. Please see the Provider Manual for additional credentialing information.

• New Practitioner Form
• Practitioner Change Form
• Practitioner Termination Form
• New Location Form
• Location Termination Form

Not a Quartz Provider?

Please complete the appropriate application.

Become a Quartz Provider

Become a Quartz Chiropractic Provider

Become a Quartz DME, Home Health, or Infusion Provider

Medical Management

• General Prior Authorization Request Form 
• Skilled Nursing Facility Weekly Review Form
• Fulcrum Out-of-Network Chiropractic Prior Authorization Form

Health Services

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

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)