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 Form

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

• Request for Medicare Prescription Drug Redetermination Form

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)
• Fitness Reimbursement Form
• 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