Secure Email
Grievance Forms
Language Translation
Login
Member
Group
Dental Office
Office Vendor
Login
Member
Group
Dental Office
Office Vendor
Members
Welcome to Member Services!
Find a Dentist
Community Smiles Program
Member COVID-19 Resources
Group & Plan Partner Sites
LIBERTY Dental Plan Language Needs Survey
Oral Health & Wellness Tips
FAQs
File a Grievance or Appeal
Forms & Literature
Medi-Cal
Member - Contact Us
Providers
Providers
Disclosure of Ownership & Control Interest Form Requirements
Contract With Us
Join Our Network
Provider Portal Registration
Value-Based Program (VBP)
Secure Email Portal
Provider Resource Library
Directory Information Validation (DIV)
Provider TeleDentistry Resources
Provider COVID-19 Resources
Clinical Criteria Guidelines & Practice Parameters
Provider Compliance Training
Florida Medicaid Webinar
Americans with Disabilities Act (ADA) Survey
Frequently Asked Questions
Secured Documents
Self Service Tools
Provider Newsletters
Providers - Contact Us
Brokers
Welcome
Request a Quote
California Application
Missouri Application
Nevada Application
All Other States
Agents & Brokers - Contact Us
Programs
Medicaid
Medi-Cal
Medicare Advantage
Commercial
Individual & Family Plans
Request a Quote
State Sites
California
Florida
Hawaii
Illinois
Missouri
Nevada
New Jersey
New York
Oklahoma
Texas
All Other States
Find a Dentist
About LIBERTY
About LIBERTY
Careers
Compliance
News & Events
Privacy
Trust Center
Contact Us
Health Risk Assessment
FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Adult - Health Risk Assessment - Spanish
Child - Health Risk Assessment - Spanish
Adult - Health Risk Assessment
Child - Health Risk Assessment
Coordination of Benefits
Email Authorization
Enroll in a Healthy Behavior Program
Formulario de autorización
File a Grievance or Appeal
File a Grievance Spanish
Leave Feedback & Suggestions
Update Contact Info
General Contact Us
FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Adult - Health Risk Assessment - Spanish
Child - Health Risk Assessment - Spanish
Adult - Health Risk Assessment
Child - Health Risk Assessment
Coordination of Benefits
Email Authorization
Enroll in a Healthy Behavior Program
Formulario de autorización
File a Grievance or Appeal
File a Grievance Spanish
Leave Feedback & Suggestions
Update Contact Info
General Contact Us
FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Adult - Health Risk Assessment - Spanish
Child - Health Risk Assessment - Spanish
Adult - Health Risk Assessment
Child - Health Risk Assessment
Coordination of Benefits
Email Authorization
Enroll in a Healthy Behavior Program
Formulario de autorización
File a Grievance or Appeal
File a Grievance Spanish
Leave Feedback & Suggestions
Update Contact Info
General Contact Us
2017
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
2018
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.
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
.
Complete un formulario por cada persona de su familia queesté inscrita en LIBERTY. Si tiene preguntas, llame a LIBERTY al número gratuito 1.833.276.0850. Unrepresentante está disponible para hablar con usted de lunes a viernes, de 8:00 a. m. a 7:00 p. m. Losusuarios de TDD/TTY deben marcar el número 1.877.855.8039.
Completar este formulario es voluntario. No se le denegará atención en función de sus respuestas
confidenciales.
Last Date of Update 12/22/2021
Nombre del miembro:
Required
Apellido del miembro:
Required
Fecha de nacimiento:
Required
Please ensure your entry is valid.
Número de identificación de Medicaid:
Required
1. ¿Han pasado más de 12 meses desde su última consulta dental?
Si
No
N/A
2. ¿Siente dolor al ingerir alimentos fríos, calientes o azucarados?
Si
No
N/A
3. ¿Siente dolor cuando le salen los dientes?
Si
No
N/A
4. ¿Tiene un diente o dientes infectados?
Si
No
N/A
5. ¿Tiene un diente o dientes rotos?
Si
No
N/A
6. ¿Tiene la boca seca?
Si
No
N/A
7. ¿Le sangran las encías cuando se cepilla o usa hilo dental?
Si
No
N/A
8. ¿Ha tenido algún tratamiento de las encías (periodontal)?
Si
No
N/A
Fecha del último tratamiento:
Please ensure your entry is valid.
9. ¿Lleva dentaduras postizas o parciales?
Si
No
N/A
10. ¿Está recibiendo actualmente radiación o quimioterapia?
Si
No
N/A
11. ¿Está embarazada?
Si
No
N/A
12. ¿Consulta con un médico regularmente por alguna condición médica crónica?
Si
No
N/A
Marque todas las opciones que correspondan:
Cáncer
Diabetes
Enfermedad renal
Otros
13. ¿Sufre o se asocia con una discapacidad mental o física?
Si
No
N/A
Entiendo que esta información se divulgará con mi nuevo plan dental.
Si
Si considera que necesita ver a un dentista antes de que LIBERTY se comunique con usted, comuníquese con su consultorio dental o busque atención en un hospital.
Please only click Submit once
Submission Success
×