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
- Federal Brochure
- Prescription Drug Benefit Brochure
- Preventive Services Covered Under the Affordable Care Act
- Prescription Drug Formulary
- Notice of Privacy Practices
Get an Answer Online
Wisconsin PricePoint Tool – Get basic, facility-specific information about health care services and charges.
- Determination of Benefits Worksheet (PDF)
- Drug Formulary (choose your formulary, then download the document)
- Authorization for Disclosure of Protected Health Information Form
- Health Plan Transition Form (PDF)
- Member Reimbursement Form (PDF) (direct Member Reimbursement Form for medications)
- Member Claim Form (PDF) (for health care other than medications)