Medicare Advantage Members

Forms

Plan Benefit Selection Form

2023 Plan Benefit Selection Forms

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

​​​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)

Member Dental Claim Form

Payment Change Form

Completed forms can be mailed or faxed to:

Quartz Medicare Advantage (HMO)
840 Carolina Street
Sauk City, Wisconsin 53583

Fax: (608) 881-8396