Quartz Provider Forms

Dual Special Needs Plan Model of Care Attestation 2025

Quartz Health Solutions, Inc. is required to maintain a record of your annual Model of Care training. To receive credit for completing this training complete the form below and submit.

Section 1: Provider Information

Name *

Provider NPI *

Section 2: Facility Information

Practice or Facility Name *

Facility Phone Number *

County

State *

Group/Billing Tax ID (do not use SSN) *

Group/Billing Tax ID #2 (do not use SSN)

Group/Billing Tax ID #3 (do not use SSN)

*Indicates a required field