Medicare Advantage Members

Forms + Resources


Plan Benefit Selection Form

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 refer to this form).

Delta Dental Certificate of Coverage

Dental Disenrollment Form (English | Español)

Determination of Benefits Worksheet

Member CashCard Reimbursement Form (fitness membership and medical ride transportation)

Member Dental Claim Form

Member Medical Claim Form (English | Español)

Payment Change Form

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.

We're here for you.

Thanks for choosing Quartz Medicare Advantage. If you have questions or need support, your local Quartz Champion is here for you.