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
- 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.
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.