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Health Risk Assessment

FL Medicaid Home
Authorization for Release of Health Information
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Email Authorization
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Formulario de autorización
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FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
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
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

LIBERTY Dental Plan Corporation received full Dental Plan accreditation by URAC as of 7/1/2019

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.

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:

Apellido del miembro:

Fecha de nacimiento:

Número de identificación de Medicaid:

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:

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 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.

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