Medicare Advantage Members

Forms + Resources



To access the Quartz Medicare Advantage enrollment application, please visit the enrollment page.

Plan Benefit Selection Form

To change plans, please complete the following form:

2023 Plan Benefit Selection Forms

Standard Print | Large Print | Online Plan Benefit Selection Form Tool

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 refer to this form).

.Delta Dental Certificate of Coverage

Dental Disenrollment Form (English | Español)

Determination of Benefits Worksheet

Member CashCard Reimbursement Form (fitness membership and medical ride transportation)

Member Dental Claim Form

Member Medical Claim Form (English | Español)

Payment Change Form

Completed forms can be mailed or faxed to:

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

Fax: (608) 881-8396

Appeals + Grievances

We provide quality service to our members. Our goal is to continuously improve the care and service members receive. You may have a concern at some point. As a member, you have the right to voice a complaint or appeal a decision made by Quartz Medicare Advantage.

Welcome. We're Happy You're Here!

Thank you for choosing Quartz Medicare Advantage. We are honored that you have entrusted us with your health insurance needs, and we are committed to making your experience be the best it can be.