Access the Forms You Need
Get secure and convenient access to member forms and resources through MyChart.
Determination of Benefits Form
Use this form to help determine costs you may incur prior to receiving health care services. To complete the form, you will have to ask your provider for certain medical coding information, including procedure codes, procedure modifiers, and unit codes for the services.
Health Risk Assessment (HRA) on the Quartz Well Portal
You can also contact Quartz Customer Service at (800) 362-3310.
Printed materials you can request include:
- Provider Directory
- Member Guide
- Certificate of Coverage
- Prescription Drug Benefit Brochure
- Preventive Services Covered Under the Affordable Care Act
- Prescription Drug Formulary
- Notice of Privacy Practices
Drug Formulary (choose your formulary, then download the document)
Member Reimbursement Form (direct member Reimbursement Form for medications)
(for health care other than medications)