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Dual Eligible Forms & Resources

Quartz Medicare Advantage Dual Eligible with Rx

Enrollment

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

Other forms
Submitting forms

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

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.

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! We're dedicated to providing the quality coverage you deserve. We're here for you if you have questions.