Child - Health Risk Assessment - Liberty Dental Plan

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LIBERTY Dental Plan Corporation received full Dental Plan accreditation by URAC as of 7/1/2019

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.

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.

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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.


	Please only click Submit once