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Individual & Family Plan Members

Forms + Resources

Thank you for choosing ​Quartz! We want to make it as easy as possible for you to use your health plan. To help you, we’ve created this member kit to walk you through important details.

Access the forms you need.

Get secure and convenient access to member forms and resources through MyChart.

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Change Your Primary Care Physician (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.

Health Risk Assessment (HRA) on the Quartz Well Portal

Order or Print an ID Card

Order Printed Materials

Other Insurance Questionnaire

Get an Answer Online — Right now!

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

Downloadable Forms

Appointment of Authorized Representative for Appeal Form

Determination of Benefits Worksheet

Drug Formulary (choose your formulary, then download the document)

Authorization for Disclosure of Protected Health Information Form

Health Plan Transition Form

Member Reimbursement Form (direct member reimbursement form for medications)

Member Claim Form (for health care other than medications)

Recurring Payment Authorization Form

Essential Information and Free Screening Tools

Pharmacy Information and Prior Authorization

View the most recent issue of the Member Newsletter

Appeals & Grievances

You or your authorized representative may request an initial decision or appeal. Your prescriber or treating provider may also request it for you.

Contact Us

Quartz is committed to providing superior customer service. That's one reason we offer so many ways to reach us.