Authorize a Representative


LIBERTY must get your written authorization to use or disclose protected health information to someone other than you (except where permitted by the Privacy Rule, for example, for treatment, payment or health care operations).

To authorize LIBERTY to communicate with your representative, please complete the Authorization Form linked below and return to privacy@libertydentalplan.com. You may also submit your completed Authorization Form by these contact methods:

Our contact details

Address

Privacy Officer

LIBERTY Dental Plan

340 Commerce, Suite 100, Irvine, CA 92602

Email

privacy@libertydentalplan.com  

Fax Number

888.273.2718

Telephone

888.704.9833

 

To access an Authorization Form Click 

Do You Need Extra Help? If you need assistance or another format (for example: another language, audio, large print, braille) please contact us at 888.704.9833.

Privacy

Authorize a Representative


LIBERTY must get your written authorization to use or disclose protected health information to someone other than you (except where permitted by the Privacy Rule, for example, for treatment, payment or health care operations).

To authorize LIBERTY to communicate with your representative, please complete the Authorization Form linked below and return to privacy@libertydentalplan.com. You may also submit your completed Authorization Form by these contact methods:

Our contact details

Address

Privacy Officer

LIBERTY Dental Plan

340 Commerce, Suite 100, Irvine, CA 92602

Email

privacy@libertydentalplan.com  

Fax Number

888.273.2718

Telephone

888.704.9833

 

To access an Authorization Form Click 

Do You Need Extra Help? If you need assistance or another format (for example: another language, audio, large print, braille) please contact us at 888.704.9833.