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.
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
Get an Answer Online — Right now!
Wisconsin PricePoint Tool – Get basic, facility-specific information about health care services and charges
- Appointment of Authorized Representative for Appeal Form (PDF)
- 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)
- Recurring Payment Authorization Form (PDF)
Essential Information and Free Screening Tools
View the most recent issue of the Member Newsletter