Forms
Plan Benefit Selection Form
2022 Plan Benefit Selection Forms
Standard Print | Large Print | Español
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 Medical Claim Form (English | Español)
Completed forms can be mailed or faxed to:
Quartz Medicare Advantage (HMO)
840 Carolina Street
Sauk City, Wisconsin 53583
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.