Quartz Dual Eligible Members

Forms + Resources


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

Other Forms

Authorization for Disclosure of Protected Health Information form

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 (English | Español)

Determination of Benefits worksheet

Quartz CashCard Reimbursement form (for fitness membership and medical ride transportation)

Member Dental Claim Form

Member Medical Claim Form (English | Español)

Completed forms can be mailed or faxed to:

Quartz Medicare Advantage (HMO)
2650 Novation Parkway
Fitchburg, WI 53713

Fax: (608) 881-8396

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.

Welcome! We're happy you're here.

Thank you for choosing Quartz Dual Eligible! Life is what you make it, and we're dedicated to providing you coverage that helps you feel confident in living well and embracing the moments that matter most.