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Page Updated On 01/19/2022

Medicare Advantage Members

Forms + Resources

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

Fitness Reimbursement Form – 2021 (English | Español

Member Medical Claim Form (English | Español)

Member Dental Claim Form

Payment Change Form

Quartz CashCard Approved Over-the-Counter Items

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.

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.