My Forms

Enrollment

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

Prescription (Part D) forms

To request an initial Part D coverage determination or exception, please use this form:

• Request for Medicare Prescription Drug Coverage Determination

To request a Part D redetermination, first-level appeal, please use this form

• Request for Medicare Prescription Drug Coverage Re-determination

Other forms

• Member Claim Form
• Payment Change Form
• Authorization for Disclosure of Protected Health Information Form
• Appointment of Representative Statement 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). ​​

Completed forms can be mailed or faxed to:

Quartz Medicare Advantage (HMO)
840 Carolina Street
Sauk City, Wisconsin 53583

Fax: (608) 881-8396