Group & Employer Plan Members Forms and Resources

Access the forms you need

Get secure and convenient access to member forms and resources by logging into MyChart. In MyChart, you can:

• Send a secure message
• Change your address
• Change your primary care provider (PCP)
• 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.
• Order or print an ID card
• Order printed materials
• Other insurance questionnaire

Printed materials

If you would like printed materials, complete the Request Materials form in Quartz MyChart, or send a message.

You can also contact Quartz Customer Success 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

Get an answer online — Right now!

• Covered Hearing Aids
• Find a Doctor
• Health topics
• Summary of Benefits and Coverage Lookup
• Wisconsin PricePoint Tool – Get basic, facility-specific information about health care services and charges
• HSA Bank’s calculator tool

Forms

• Determination of Benefits Worksheet (PDF)
• Drug Formulary (Choose your formulary, then download the document)
• Appointment of Representative for appeal form (PDF)
• Health Plan Transition form (PDF)
• Prescription reimbursement request form (PDF) (Direct member reimbursement for medications)
• Member Claim form (PDF) (for Direct member reimbursement for health care other than medications)

Essential information and resources

• Pharmacy information and prior authorization
• Preventive services covered under the Affordable Care Act –Wisconsin | Illinois
• Contraceptive services covered under the Affordable Care Act 
• View Your Rights and Protections Against Surprise Medical Bills

Protected Health Information (PHI) Authorization

• You have the right to allow someone else to access your Protected Health Information (PHI). To do so, please complete and submit the Authorization for Disclosure of Protected Health Information form at QuartzBenefits.com/phiform or in Quartz MyChart.
• You may also print and mail the Authorization to Disclosure of Protected Health Information form and send it to Quartz.