Provider Participation Application | Quartz

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Thank you for your interest in becoming a Quartz participating provider. Please complete the webform below or the PDF application. Your application will be evaluated for participation in all Quartz-affiliated networks.

Quartz requires network providers to be Medicaid and/or Medicare certified.

* indicates required information

Legal Entity Name *

Name of d/b/a (if applicable)

Tax ID Number *

Website

Phone Number *

Fax Number

Mailing Address *

City *

State *

Zip Code *

Primary Contact Name *

Primary Contact Phone *

Primary Contact Email *

Total Number of Locations *

Total Number of Practitioners *

Medicare Certified Facility *

Yes
No

Medicaid Certified Facility *

Yes
No

Facility Type *

Hospital
Clinic
Nursing Home
Surgery Center
Behavioral Health Inpatient/Residential
ACA Essential Care Provider
Other... This choice will expand a text box

Practice Specialties *

PCP
Specialty
Behavioral Health
Optometry
OT/PT/Speech
Autism
Dialysis
Other... This choice will expand a text box

Is the facility ADA accessible *

Yes
No

Describe the services you provide *

Primary hours of operation *

After hours/emergency call process *

Practitioner #1 Name and Degree

Practitioner #1 Medicare Number

Practitioner #1 Medicaid Number

Practitioner #1 Hours/Week

Practitioner #2 Name and Degree

Practitioner #2 Medicare Number

Practitioner #2 Medicaid Number

Practitioner #2 Hours/Week

Practitioner #3 Name and Degree

Practitioner #3 Medicare Number

Practitioner #3 Medicaid Number

Practitioner #3 Hours/Week

Practitioner #4 Name and Degree

Practitioner #4 Medicare Number

Practitioner #4 Medicaid Number

Practitioner #4 Hours/Week

Practitioner #5 Name and Degree

Practitioner #5 Medicare Number

Practitioner #5 Medicaid Number

Practitioner #5 Hours/Week

If you have more than 5 practitioners, we will gather details upon approval.