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Child - Health Risk Assessment

Please Complete one form for each person in your family who is enrolled in LIBERTY.  If you have questions, please call LIBERTY, toll free at 1.833.276.0850.  A representative is available to speak with you Monday through Friday, between 8:00 am and 7:00 pm.  TDD/TTY users should dial 1.877.855-8039.

 

Filling out this form is voluntary. You will not be denied care based on your confidential answers.

Member's First Name:
Member's Last Name:
Date of Birth:
Medicaid ID Number:
1. Child has a dental home/receives regular dental care?

2. Child has teeth brushed daily?

3. Do you live in an area with fluoridated drinking water?

4. Does child snack between meals?

5. Child often drinks soda, juices, or energy drinks?

6. Is English your child’s primary language?

7. Child has cavities?

8. Mother/primary caregiver has active cavities?

9. Child has special health care needs?

10. Child has plaque on teeth?

11. Child is put to bed with a bottle containing natural or added sugar?

I understand that this information will be disclosed to my new dental plan.
If you think you need to see a dentist before LIBERTY contacts you, please contact your dental office or seek care from a hospital.

Please only click Submit once