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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.























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