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Page Updated On 02/01/2022

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

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

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.

Contact Us

Quartz is committed to providing superior customer service. That's one reason we offer so many ways to reach us.