Current Network Practitioner Forms
Use this form if a new practitioner joins your clinic, leaves your clinic, or has updates to their information.
Use this form if a new facility or location is added, or if a clinic or facility is no longer available to Quartz members.
Print Versions of Online Forms
For paper submissions only.
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)
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)