Quartz Prior Authorization

Request Form
Please note: Do not use for Behavioral Health Department
Call (800) 683-2300 for Behavioral Health Prior Authorization

Fax / Mail Completed* Form to:

Medical Management, 7974 UW Health Court Middleton, WI 53562
Phone: (888) 829-5687 or (608) 821-4200; Fax: (608) 821-4207

*Please complete the entire form. Incomplete forms will be returned. Date Requested
For Non-Urgent Pre-Service Decisions: Determinations are made within 15 calendar days of receipt.
For Post-Service Decisions: Determinations are made within 30 calendar days of receipt. _____/_____/_____

PATIENT INFORMATION
Patient Name Date of Birth Member Number Date of Service

REFERRAL INFORMATION
Authorizing / Referred From: Clinic Contact: Phone Number:

Patient’s Request Date Last Seen by PCP: _____/_____/_____ Site / Location: Fax:

Referred To: Clinic Contact: Phone Number:

Site / Location: Fax:

SERVICES REQUESTED

Consult Only
Follow-up
DME
Lab
X-Ray
Home Care / Hospice
Therapy ___ST ___PT ___OT

Primary Diagnosis Code: Description:

Procedure / HCPCS Code(s): Description:

Applicable diagnostic testing performed:

Surgery: ___Inpatient ___Outpatient Coordination of Benefits
Yes
No

Description: WC
Yes
No Date of Injury / Loss __________________

MVA/Subro
Yes
No Date of Injury / Loss __________________

Other Coverage
Yes
No Ins. Co. _____________________________________________

COMMENTS (INDICATIONS FOR REFERRAL TO SPECIALIST):

Note: This referral does not guarantee payment for services. Benefits will be determined in accordance with the policy terms in effect on the date of service. Please refer to the Policy
documents (e.g. Certificate of Coverage, Benefit Riders) for a complete description of plan benefits, limitations and exclusions. Call Unity Customer Service at (800) 362-3310 if you have
questions about this referral.

UW Health Administrative Information DO NOT WRITE IN THIS AREA

Approve
Deny
Other Reference # _____________________________________________________________ R U E

Begin Date _________________________________________________ End Date _________________________________________________ # Visits __________________________

Comments:

Medical Director / Designee Signature Date

UH00266 (0618) Unity Health Plans Insurance Corporation

 Non-Discrimination & Language Access
Quartz is the brand name for a group of companies committed If you believe we failed to provide these services or
to your health: Unity Health Plans Insurance Corporation, discriminated in another way on the basis of race, color, national
Physicians Plus Insurance Corporation, Gundersen Health Plan, origin, age, disability, or sex you can file a grievance with –
Inc., and Gundersen Health Plan Minnesota. These companies Kristie Meier, Compliance Officer
are separate legal entities. In this notice “we” refers to all Quartz 840 Carolina Street
companies. Sauk City, WI 53583
For assistance understanding these materials in a language Phone: (800) 362-3310
other than English, call (800) 362-3310 and a Customer TTY / TDD: 711 or toll free (800) 877-8973
Service representative will assist you. TTY users should call Fax: (608) 644-3500
711 or (800) 877-8973. Email: [email protected]
We comply with applicable Federal civil rights laws and do not You can file a grievance in person or by mail, fax or email. If you
discriminate on the basis of race, color, national origin, age, need help filing a grievance, Kristie Meier, Compliance Officer,
disability, sex, gender identity, sexual orientation or is available to help you. You can also file a civil rights complaint
health status. with the U.S. Department of Health and Human Services, Office
We provide free aids and services to people with disabilities to for Civil Rights, electronically through the Office for Civil Rights
communicate effectively with us, such as – Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/
lobby.jsf or by mail or phone at:
J Qualified sign language interpreters
J Written information in other formats (large print, audio, U.S. Department of Health and Human Services
200 Independence Avenue
accessible electronic formats, other formats)
SW Room 509F, HHH Building
We provide free language services to people whose primary Washington, D.C. 20201
language is not English, such as – (800) 368-1019; (800) 537-7697 (TDD)
J Qualified interpreter
Complaint forms are available at hhs.gov/ocr/office/file/index.html
J Information written in other languages
Quartz is a Qualified Health Plan issuer in the Health
If you need these services, contact Customer Service at Insurance Marketplace in certain states. To learn more, visit
(800) 362-3310. the Health Insurance Marketplace at Healthcare.gov.

For help to translate or understand this, please call (800) 362-3310, TTY / TDD: 711 / (800) 877-8973.
Spanish – Este aviso contiene información importante. Este aviso Chinese – 本通知含有重要的訊息。本通知包含了關于您通
contiene información importante acerca de su solicitud o cobertura 過 Quartz 提交之申請或保險責任範圍的重要訊息。請留意
a través de Quartz. Preste atención a las fechas clave que contiene
este aviso. Es posible que deba tomar alguna medida antes de 本通知內的重要日期。您可能需要在若幹截止日期之前采取
determinadas fechas para mantener su cobertura médica u obtener 行動，以維持您的健康保險責任範圍或者費用補貼。您有
ayuda con los costos. Usted tiene derecho a recibir esta información 權利免費獲得以您母語撰寫的本訊息和各種幫助。請致電
y ayuda en su idioma sin costo alguno. Llame al (800) 362-3310.
TTY / TDD: 711 / (800) 877-8973.
(800) 362-3310。聾啞人電話：711 / (800) 877-8973.。
Russian – Настоящее уведомление содержит важную
Hmong – Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb.
Tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim
информацию. Это уведомление содержит важную
ntawv thov kev pab los yog cov kev pab kam them nqi kho mob los
информацию о вашем заявлении или страховом
ntawm Quartz. Saib cov caij nyoog ceeb hauv daim ntawv no. Tej
покрытии через Quartz. Посмотрите на ключевые
zaum koj kuj yuav tau ua qee yam kom tsis pub dhau cov caij nyoog
даты в настоящем уведомлении. Вам, возможно,
koj thiaj yuav tau txais kev pab kam them nqi kho mob los yog kev
потребуется принять меры к определенным
pab them tej nqi kho mob. Koj muaj cai tau cov ntshiab lus no thiab
предельным срокам для сохранения страхового
tau kev pab ua koj hom lus pub dawb rau koj.
покрытия или помощи с расходами. Вы имеете
Hu rau (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
право на бесплатное получение этой информации
и помощь на вашем языке. Звоните по телефону
Vietnamese – Thông báo này cung cấp thông tin quan (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
trọng. Thông báo này có thông tin quan trọng bàn về đơn
nộp hoặc hợp đồng bảo hiểm qua chương trình Quartz. Xin Laotian – ແຈ້ງການນີ້ມີຂໍ້ມູນສຳຄັນ. ແຈ້ງການນີ້ມີຂໍ້ມູນ
xem ngày then chốt trong thông báo này. Quý vị có thể phải ທີ່ສຳຄັນກ່ຽວກັບການສະໝັກຂໍ ຫຼື ການຄຸ້ມຄອງຂອງທ່ານ
thực hiện theo thông báo đúng trong thời hạn để duy trì ໂດຍຜ່ານ Quartz. ໃຫ້ເບິ່ງກຳນົດວັນທີສຳຄັນຢູ່ໃນແຈ້ງກ
bảo hiểm sức khỏe hoặc được trợ trúp thêm về chi phí. Quý ານນີ້. ທ່ານອາດຈະຕ້ອງໄດ້ໃຊ້ເວລາດຳເນີນການຕາມກຳ
vị có quyền được biết thông tin này và được trợ giúp bằng
ngôn ngữ của mình miễn phí. Xin gọi số (800) 362-3310.
ນົດເວລາທີ່ແນ່ນອນ ເພື່ອຮັກສາການຄຸ້ມຄອງຂອງທ່ານ ຫຼື
TTY / TDD: 711 / (800) 877-8973. ການຊ່ວຍເຫຼືອທີ່ມີຄ່າໃຊ້ຈ່າຍ. ທ່ານມີສິດໄດ້ຮັບຂໍ້ມູນຂ່າວສານ ແລະ
ການຊ່ວຍເຫຼືອເປັນພາສາຂອງທ່ານ ໂດຍບໍ່ເສຍຄ່າໃຊ້ຈ່າຍໃດໆ.
ໃຫ້ໂທຫາເບີ (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
German – Diese Benachrichtigung enthält wichtige Informationen. Pennsylvanian Dutch – Die Bekanntmaching gebt wichdichi
Diese Benachrichtigung enthält wichtige Informationen bezüglich Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei
Ihres Antrags oder Ihres Krankenversicherungsschutz durch Quartz. Application oder Coverage mit Quartz. Geb Acht fer wichdiche
Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes duh
könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren muscht, an beschtimmde Deadlines, so ass du dei Health Coverage
Krankenversicherungsschutz oder Hilfe mit den Kosten zu erhalten. bhalde kannscht, odder bezaahle helfe kannscht. Du hoscht es Recht
Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer fer die Information un Hilf in deinre eegne Schprooch griege, un die
Sprache zu erhalten. Rufen Sie an unter (800) 362-3310. Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht
TTY / TDD: 711 / (800) 877-8973. du (800) 362-3310 uffrufe. TTY / TDD: 711 / (800) 877-8973.

Arabic – .Quartz Polish – To zawiadomienie zawiera ważne informacje.To

zawiadomienie zawiera ważne informacje dotyczące Państwa
. . wniosku lub zakresu ubezpieczenia w Quartz. Proszę
zwrócić uwagę na ważne daty podane w zawiadomieniu.
. Mogą to być terminy dokonania określonych czynności
.TTY / TDD: 711 / (800) 877-8973 .(800) 362-3310 koniecznych do zachowania ubezpieczenia zdrowotnego
. lub uzyskania pomocy związanej z kosztami. Mają Państwo
prawo do otrzymania tej informacji oraz uzyskania pomocy
French – Cet avis contient des informations importantes. Cet avis bezpłatnie w swoim języku. Proszę dzwonić pod numer:
contient des informations importantes concernant votre demande ou (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
sur la prise en charge par Quartz. Rechercher les dates importantes
sur le présent avis. Il se peut qu’une action de votre part soit Hindi –
nécessaire avant une certaine date afin de conserver votre couverture
Quartz
santé ou votre aide sur les frais. Vous avez le droit d’obtenir
gratuitement ces informations et une assistance dans votre langue.
Appelez le (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.

Korean – 본 통지서에는 중요한 정보가 들어 있습니다. 본 통지서에는

귀하의 신청 또는 Quartz를 통한 보험보장에 관한 중요한 정보가 들어 800) 362-3310
있습니다. 본 통지서에 나와있는 중요한 날짜를 찾아보십시오. 귀하는 TTY / TDD: 711 / (800) 877-8973.
귀하의 건강 보험보장을 유지하기 위해 특정 마감일까지 조치를 취해야
할 수도 있거나, 비용에 관한 도움이 필요할 수도 있습니다. 귀하는 귀하가 Albanian – Ky njoftim përmban informacion të rëndësishëm. Ky
사용하는 언어로 이러한 정보와 도움을 무료로 받을 권리가 있습니다. (800) njoftim përmban informacion të rëndësishëm për aplikimin ose
mbulimin tuaj nëpërmjet Quartz. Kontrolloni për data të rëndësishme
362-3310 번으로 전화하십시오. TTY / TDD: 711 / (800) 877-8973. në këtë njoftim. Mund t’ju duhet të ndërmerrni veprim brenda afatave
Tagalog – Ang Abisong ito ay may Importanteng Impormasyon. të caktuara për të mbajtur mbulimin tuaj shëndetësor ose për
Ang abisong ito ay may importanteng impormasyon tungkol sa ndihmën me koston. Keni të drejtë ta merrni këtë informacion dhe
aplikasyon o proteksiyon mo sa pamamagitan ng Quartz. Hanapin ndihmë falas në gjuhën tuaj. Telefononi numrin (800) 362-3310.
ang mga pangunahing petsa na nasa abisong ito. Maaaring kailangan TTY / TDD: 711 / (800) 877-8973.
mong kumilos bago sumapit ang ilang takdang araw para mapanatili
Somali – FIIRO GAAR AH: Haddii aad ku hadashid af Soomaali,
ang proteksiyon ng kalusugan mo o para makatulong sa mga
gastusin. Karapatan mong makuha ang impormasyon na ito na adeegyada caawimada luuqada, ayaa waxaa laguugu siinayaa
nasa wika mo nang walang gastos. Tumawag sa numerong bilaash, waa laguu heli karaa. 1-800-362-3310
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973. (TTY: 1-800-877-8973) bilbilaa.

Cushite – Oroomiffa XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Amharic –
Quar

Karen –
Mon-Khmer, Cambodian –
TTY / TDD: 711 / (800) 877-8973.

Serbocroatian – OBAVJEŠTENJE: Ako govorite srpskohrvatski, usluge jezičke pomoći dostupne su vam besplatno.
Nazovite (800) 362-3310 TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711 / (800) 877-8973.
Thai – เรียน: ถา้ คุณพดู ภาษาไทยคุณสามารถใชบ้ ริการช่วยเหลือทางภาษาไดฟ้ รี โทร (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Gujarati –

Urdu –

Italian – ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Greek – ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες
παρέχονται δωρεάν. Καλέστε (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.

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