My Forms

Enrollment

To access the Quartz Medicare Advantage enrollment application, please visit the enrollment page.

Plan Benefit Selection Form

To change plans, please complete the following form:

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 | Spanish)
• Determination of Benefits Worksheet
• Fitness Reimbursement Form (English | Spanish) 
• Member Medical Claim Form (English | Spanish)
• 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