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
  
• 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 for Disclosure Protected Health Information form and send it to Quartz.

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
• 211.org