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.

Health Services

Health Management Program Referral Forms 
(See Resources for Your Patients Section)


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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