Child - Health Risk Assessment - Liberty Dental Plan

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?	Yes No N/A
2. Child has teeth brushed daily?	Yes No N/A
3. Do you live in an area with fluoridated drinking water?	Yes No N/A
4. Does child snack between meals?	Yes No N/A
5. Child often drinks soda, juices, or energy drinks?	Yes No N/A
6. Is English your child’s primary language?	Yes No N/A
7. Child has cavities?	Yes No N/A
8. Mother/primary caregiver has active cavities?	Yes No N/A
9. Child has special health care needs?	Yes No N/A
10. Child has plaque on teeth?	Yes No N/A
11. Child is put to bed with a bottle containing natural or added sugar?	Yes No 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.


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