Provider Forms – Current Network Practitioner & Facility

Practitioner & facility notification forms

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

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 reconsideration forms

Current in-network providers should utilize My Quartz Tools for claim reconsideration. The paper forms below are to be used by out-of-network providers only.

Claim adjustment request form

Use this form 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

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