CHRISTUS Health Medicare Guardian (HMO) Forms
- Annual Attestations from FDRs (PDF)
- Annual Compliance Program Effectiveness Assessment- Medicare Advantage (PDF)
- Breach Notification PHI- Reporting Guideline (PDF)
- Code of Ethics (PDF)
- Code of Ethics for CHRISTUS Health Plan Louisiana (PDF)
- Communications Regarding Regulatory Changes (PDF)
- Compliance Training and Education (PDF)
- Corrective Action (PDF)
- Fraud, Waste, and Abuse (PDF)
- Monitoring and Auditing (PDF)
- Non-Discrimination Notice (PDF)
- Non-Retaliation Policy (PDF)
If you choose to go out-of-network for your dental care, you may be reimbursed for your treatment. Complete the patient and subscriber information on the Delta Dental Claims Form.
Mail the completed form and a copy of the dentist’s Statement of Treatment (or detailed receipt) to:
Delta Dental Insurance Company
PO Box 1809
Alpharetta, GA 30023
The Statement of Treatment or detailed receipt must include:
- Name, address, and complete phone number of dentist
- Date each service was performed
- Description, procedure code, and fee of each service performed
- List of affected teeth
- Total cost of services performed
- Dentist’s National Provider Identifier (NPI)
- Dentist’s Tax Identification Number (TIN)
- State license number
- Specialty code
Important note: If the Statement of Treatment or similar document you receive from your dentist is missing any of the information listed above, please enter it on the claim form. A dental office staff member can provide you with the dentist and treatment information.
Be sure to make a copy of the completed claim form and the dentist’s Statement of Treatment or detailed receipt for your records.
Ways to Enroll
We provide three enrollment options: Online, Application (fax or mail) and through Medicare.gov.
Enroll online - Enroll Now
2024 Enrollment Applications (fax or email)
- 2024 Short Enrollment Application (PDF)
- 2024 Short Enrollment Application en Espanol (PDF)
- 2024 New Mexico Enrollment Application (PDF)
- 2024 New Mexico Enrollment Application en Espanol (PDF)
- 2024 Enrollment Application Northeast Texas (PDF)
- 2024 Enrollment Application Northeast Texas en Espanol (PDF)
- 2024 Enrollment Application Southeast Texas (PDF)
- 2024 Enrollment Application Southeast Texas en Espanol (PDF)
- 2024 Enrollment Application South Central and East Texas Medicare Expansion Counties (PDF)
- 2024 Enrollment Application South Central and East Texas Medicare Expansion Counties en Espanol (PDF)
Disenrollment Applications
Provider Search Tools
Printable Provider & Pharmacy Directories
ENGLISH
- Guardian 2024/2025 Provider Directory New Mexico - English (PDF)
- Guardian 2024/2025 Provider Directory Texas - English (PDF)
SPANISH