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File a Grievance

To submit a written Grievance, please use the link below; to print and mail to LIBERTY Dental Plan, or complete the online form below.

Member Grievance Form   -   Spanish Version

Provider Grievance Form

Please complete the Grievance Form with all related information.  LIBERTY considers a complaint and grievance as the same.  Please provide information regarding your complaint and your desired or proposed resolution to the complaint.  Your complaint will be considered by LIBERTY the next business day following successful submission of this Form by you. LIBERTY will send a written acknowledgement letter within five (5) days of receipt of this Form. LIBERTY will review your complaint and send you written notice of our determination within thirty (30) days of receipt of this Form. So that we may properly research and resolve this matter, a copy of your completed Grievance Form may be forwarded to the dentist(s) who provided treatment.

If you would like assistance in completing this form, please contact our Member Services Department at 1-866-609-0418.

Florida Medicaid members are required to exhaust the Plan’s appeals process before you can request a State Fair Hearing. Appeals must be filed within 90 days from the denial letter.

You may request a fast resolution to your grievance or appeal. If we find that you meet the criteria, you will be provided a response within 3 business days.

NOTE: (Items marked with an " * " are required fields)

*First Name
*Last Name
Address (line 1)
Address (line 2)
City
State
Zip Code
Home Phone
Alternate Phone
*Email Address
Group Name
Dentist/Facility Name
Complaint/Grievance
Recommendation (action requested)

Please only click Submit once