CHRISTUS Health Medicare Guardian (HMO) Forms

2025 documents

2025 Annual Notice of Change 

ENGLISH

SPANISH

2025 Evidence of Coverage 

ENGLISH

SPANISH

2025 Summary of Benefits 

ENGLISH

SPANISH

Provider Directory 

Provider Search Tools

Printable Provider & Pharmacy Directories

Medicare Advantage Guardian 

ENGLISH

SPANISH

24-Hour Nurse Line 
CHRISTUS Health, Medicare Advantage (HMO) members have access to a toll-free 24-hour nurse line. Call the number 844-581-3174 to speak with a registered nurse at any time, day or night. If you are experiencing a medical emergency, please dial 911.
Compliance Policies 
Dental Reimbursement 

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.

Enrollment & Disenrollment Forms 

Ways to Enroll

We provide three enrollment options:

  • Online
  • Application (fax or mail)
  • and through Medicare.gov.

2025 Enrollment Applications (fax or email)

Disenrollment Applications

Authorization to Disclose Personal Information 
Appeals and Grievances 
Medical Reimbursement Form 

Appointment of Representative 

H1189_WEB25MM3012_M | Last Updated 04/15/25