To access the Quartz Medicare Advantage enrollment application, please visit the enrollment page.
Prescription (Part D) forms
- To request an initial Part D coverage determination or exception, please use this form:
- To request a Part D redetermination, first-level appeal, please use this form:
- Member Claim Form
- Payment Change Form
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Statement Form (If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal or grievance, please refer to this form).
Completed forms can be mailed or faxed to:
Quartz Medicare Advantage (HMO)
840 Carolina Street
Sauk City, Wisconsin 53583
This webpage was updated on June 3, 2020.