CHRISTUS Health Medicare Guardian (HMO) Forms

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