Dual Eligible Members Forms & Resources

Enrollment

To access the Quartz Medicare Advantage Dual Eligible with Rx enrollment application, please visit the enrollment page.

Forms

• Appointment of Representative form – If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal, or grievance, please use this form.
• Delta Dental Certificate of Coverage
• Dental disenrollment form
• Determination of Benefits worksheet
• Request for Medicare prescription drug coverage determination
• Part D prescription drug reimbursement form
• Quartz CashCard reimbursement form – for fitness membership and medical ride transportation
• Member medical claim form
• Member dental claim form

Submitting forms

Completed forms can be mailed or faxed to:

Quartz Medicare Advantage (HMO)
2650 Novation Parkway
Fitchburg, WI 53713
Fax: (608) 881-8396

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 Release Protected Health Information form and send it to Quartz.

Case Management

All Quartz Medicare Advantage Dual Eligible with Rx members have access to case management services upon enrollment at no extra cost.

An entire care team works with members to ensure they get the most of your benefits, including:

• Coordinate care and services
• Develop care plans
• Create and meet health goals

How does case management work?

The case management team includes a registered nurse and/or social work care manager. They work closely with you and your caregivers to help you get the best care possible.

Your team will connect with you at least once a year. More often, if needed. If you have not yet connected with your team, please call (866) 884-4601.

Other health management resources

• Managing Your Medicines
• When Your Chronic Condition Causes Depression

Health information

By clicking the links below you will leave the Quartz Dual Eligible website

Free health information and resources in your community are a call or click away:

• Great Rivers 2-1-1
• Dial 2-1-1 or (800) 362-8255
• 211wisconsin.communityos.org
• www.211.org