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Provider Forms

Forms are required for contracted providers when there is a change within their facility. Please see the Provider Manual for additional credentialing information.

Current Network Practitioner Forms

Practitioner Notification Form

Use this form if a new practitioner joins your clinic, leaves your clinic, or has updates to their information.

Facility Notification Form

Use this form if a new facility or location is added, or if a clinic or facility is no longer available to Quartz members.

Claims

For paper submissions only.

Claim Adjustment Request Form

This form should be used when submitting a corrected/replacement claim or submitting requested documents (i.e., itemized bills or medical records). A claim should accompany this form. (Download, print, and mail/fax)

Coding Denial Appeal Form

This form should be used when there is a request for review of coding-related denial with an explanation of why the provider feels it is coded correctly or when there is a request of Appeal of Coding denial with explanation and supporting documentation. A claim should not accompany this form. If a claim needs to be submitted, then please use the Claim Adjustment Request Form. (Download, print, and mail/fax)

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