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Adult - Health Risk Assessment - Spanish
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Adult - Health Risk Assessment
Child - Health Risk Assessment
Coordination of Benefits
Email Authorization
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Formulario de autorización
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File a Grievance Spanish
Leave Feedback & Suggestions
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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:
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
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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