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HITRUST Certified

LIBERTY received HITRUST CSF v8.1 certified status for its Health Solutions Plus core application and supporting systems as of 11/20/17
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HEDIS NCQA Certified

 LIBERTY Dental Plan was presented with a
2018 NCQA-Certified HEDIS® Compliance Audit™
by AttestHealth Care Advisors, LLC, an NCQA certified audit group.
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NCQA has reviewed and accredited LIBERTY’s Credentialing and Utilization Management functions only. For complete details on the scope of this review, visit www.ncqa.org.

Authorization for Release of Health Information

I understand and agree that:

  • This authorization is voluntary.

  • My Health information may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease, and health care program information.

  • I will not be denied treatment if I do not sign this form.

  • I will not be denied payment for health (dental) care services if I do not sign this form.

  • I will not be denied enrollment or eligibility for health care benefits if I do not sign this form.

  • The recipient of my health information could disclose it to other parties who are not included in this authorization.

  • If parties are not health (dental) plans or health (dental) providers, then the information may no longer be protected by federal privacy regulations.

  • I may revoke this authorization at any time by calling LIBERTY Dental Plan at: 1.833.276.085, by writing LIBERTY Dental Plan, P.O. Box 15149, Tampa, FL, 33684 or sending a fax to: 1.888.700.1727.

  • The revocation will not influence my dental care.


Who May Receive and Disclose my information:

I authorize LIBERTY dental plan and its affiliates to disclose my individual identifiable health information to the following person(s) or organization(s):

Last Date of Update 12/22/2021

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