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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

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.

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.

Last Date of Update 12/22/2021

Member's First Name:

Required

Member's Last Name:

Required

Date of Birth:

RequiredPlease ensure your entry is valid.

Medicaid ID Number:

Required

1. Child has a dental home/receives regular dental care?

Yes

N/A

2. Child has teeth brushed daily?

Yes

N/A

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

Yes

N/A

4. Does child snack between meals?

Yes

N/A

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

Yes

N/A

6. Is English your child’s primary language?

Yes

N/A

7. Child has cavities?

Yes

N/A

8. Mother/primary caregiver has active cavities?

Yes

N/A

9. Child has special health care needs?

Yes

N/A

10. Child has plaque on teeth?

Yes

N/A

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

Yes

N/A

I understand that this information will be disclosed to my new dental plan.

Yes

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

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