Medicare Advantage Members Forms & Resources: UW Health
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.