Medicare Advantage Members Forms & Resources: Gundersen Health System, MN
Forms
Enrollment
To access the Quartz Medicare Advantage enrollment application, please visit the enrollment page.
Plan benefit selection forms
To change plans, please complete the following form:
2024 Plan benefit selection forms
Standard print | Large print | Online plan benefit selection form tool
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 use this form).
- Delta Dental Certificate of Coverage
- Dental disenrollment form (English | Español)
- Determination of benefits worksheet
- Member CashCard reimbursement form (fitness membership and medical rides)
- Member dental claim form
- Member medical claim form (English | Español)
- Premium payment option 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
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.