Medicare Advantage Members Forms & Resources
Gundersen Quartz Medicare Advantage (HMO)
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:
2025 Plan benefit selection forms
Standard print | Large print | Spanish | Online plan benefit selection form tool
Other forms
- 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
- Supplemental dental disenrollment form
- Determination of benefits worksheet
- Member CashCard reimbursement form – For fitness membership and medical rides
- Member dental claim form
- Member medical claim form
- Part D prescription drug reimbursement form
- 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
Protected Health Information (PHI) Authorization
- You have the right to allow someone else to access your Protected Health Information (PHI). To do so, please complete and submit the Authorization for Disclosure of Protected Health Information form at QuartzBenefits.com/PHIform or in Quartz MyChart.
- You may also print and mail the Authorization to Disclosure of Protected Health Information form and send it to Quartz.
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.