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Florida Application

Thank you for your interest in marketing our dental plans. Contracting with us is a simple process by following the steps below:

Step 1: Marketing Service Agreement (MSA)

  1. Complete the Marketing Service Agreement (fillable form)
  2. Print the completed Marketing Service Agreement
  3. Sign where indicated

Step 2: Obtain a copy of your FL Insurance License

Step 3: IRS form W-9

  1. Complete a Department of the Treasury Internal Revenue Department Form W-9 (fillable form)
  2. Print the completed W-9 form (page 1 only)
  3. Sign where indicated

Step 4: Business Associate Agreement (BAA)

  1. Complete the Business Associate Agreement (fillable form).  The “Business Associate” name in the first sentence must be the Legal Name (shown on your income tax return) as it appears on Line 1 of your IRS Form W-9. 
  2. Print the completed BAA
  3. Have an officer of your company sign where indicated
  1. Complete the Non-Disclosure Statement (fillable form).  The “Contractor” name in the first sentence must be the Legal Name (shown on your income tax return) as it appears on Line 1 of your IRS Form W-9. 
  2. Print the completed NDA
  3. Have an officer of your company sign where indicated

Step 6: FFM User ID and Exchange Training Certification

  1. Include a copy of each of these documents to enroll groups on Healthcare.gov
Once you have compiled, completed and signed the above documents, you may submit them by one of three methods. 
 
  1. Mail:
    LIBERTY Dental Plan
    Attn: Client Services
    P.O. Box 26110
    Santa Ana, CA 92799-6110
  2. Fax: (949) 270-0114
  3. Email: clientservices@libertydentalplan.com.  Because the documents include your private information, please send them encrypted or password protected. 

Once we receive and approve all of the completed documents, you will receive a notification that you are contracted with LIBERTY Dental Plan.  Included will be executed copies of your Marketing Services Agreement, BAA, NDA and your assigned Broker/Agent number.  We are unable to pay any commissions until all of these documents have been completed, received and approved.

If you have any questions regarding this process, please contact our Client Services Department at
(888) 273-2997 x162.

LIBERTY Dental Plan (“LIBERTY”) requires its Agents/Brokers who may, in the course of providing services for LIBERTY, have access to members’ Protected Health Information (PHI) to execute a Business Associate Agreement (BAA) and any updates thereto.  The Business Associate Agreement sets forth all applicable privacy and security requirements under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) and Health Information for Economic and Clinical Health Act (“HITECH Act”).  In addition, LIBERTY requires its Agents/Brokers who may have access to its (or its clients’) confidential information to execute a Nondisclosure Agreement (NDA) and any updates thereto.

We look forward to working with you to provide
quality dental benefits to your clients!