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Provider Patient Resources – Refer a Patient Form

Refer a patient

Provider information

Use this form to refer a patient to a Quartz Care Management Program. Select the program that best fits your patient’s needs. We may reach out with questions.

Support for(Required)

Behavioral health

Complex and chronic conditions

Pregnancy and postpartum

Quartz Food Is Medicine Program (nourishing meals) for Quartz Medicare Advantage (HMO), Quartz Dual Eligible with Rx, Quartz BadgerCare Plus, and Medicaid SSI

Name(Required)

First Last

Clinic name

Health system

Phone

Preferred method of contact?

Phone

Patient information

Name

First Last

Address

Street address Address line 2 City State ZIP code

Phone number

Date of Birth

Reason for referral

Is the patient aware of the referral?

Yes

Please have a conversation with your patient prior to a referral.

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