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:

To access an Authorization Form Click  English  Spanish

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.

New York Medicaid members may submit the New York State Standard Form to Designate a Representative
link here