Select your plan
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
- 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
- Supplemental dental disenrollment form (English | Español)
- Determination of benefits worksheet
- Member CashCard reimbursement form – For fitness membership and medical rides
- Member dental claim form
- Member medical claim form (English | Español)
- Premium payment option form
Completed forms can be mailed or faxed to:
Quartz Medicare Advantage (HMO)
2650 Novation Parkway
Fitchburg, WI 53713
Fax: (608) 881-8396
Protected Health Information (PHI) Authorization
- You have the right to allow someone else to access your Protected Health Information (PHI). To do so, please complete and submit the Authorization for Disclosure of Protected Health Information form at QuartzBenefits.com/PHIform or in Quartz MyChart.
- You may also print and mail the Authorization to Disclosure of Protected Health Information form and send it to Quartz.