To submit a written grievance or appeal with LIBERTY Dental Plan (LIBERTY), please use the printable form linked below or complete the online form below. You can also use this form to give LIBERTY more information to help review your case. If you filed an appeal over the telephone, you can also complete this form and mail back to LIBERTY. This is optional. We will review your case without a written appeal.

• Enrollee Grievance and Appeal Form

PLEASE SEND COMPLETED SIGNED FORM TO:

• Fax to LIBERTY’s Grievances and Appeals Department fax at (833) 250-1816
• Telephone by calling LIBERTY’s Member Services Department at (833) 276-0850, or TTY 1-877-855-8039
• Electronically by using the online form below
• Emailing us at: FLGandA@libertydentalplan.com
• Mail to:

  LIBERTY Dental Plan of Florida
  Grievances and Appeals Department
  P.O. Box 15149
  Tampa, FL 33684
  

Appeals must be filed within 60 days from the date on your Notice of Adverse Benefit Determination (NABD).  Grievances can be filed at any time.

You will receive a letter confirming receipt of your grievance or appeal within 3 calendar days of receipt by LIBERTY.
You will receive a written resolution to your grievance within 30 calendar days of receipt by LIBERTY.
You will receive a written resolution to your appeal within 20 calendar days of receipt by LIBERTY.
You may request a copy of your records associated with your active grievance or appeal in writing to LIBERTY at the address listed above.

If you need help completing this form, call our Member Services Department at (833) 276-0850, or TTY 1-877-855-8039, Monday through Friday 8:00 a.m. to 8:00 p.m. (ET). We can give you an interpreter at no cost, if you need one. You or someone you authorize have the right to review your case file at any time. We’ll give you copies free of charge.

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