Forms & Literature

Language Assistance Information | ?????? | Información sobre Asistencia en su Idioma

LIBERTY Dental Plan of California Notice of Language Assistance Services
California Exchange Notice of Language Assistance Services
LIBERTY Dental Plan of Florida Notice of Language Assistance Services
Florida Exchange Notice of Language Assistance Services
LIBERTY Dental Plan of Missouri Notice of Language Assistance Services
LIBERTY Dental Plan of Nevada Notice of Language Assistance Services

For additional information, please call a LIBERTY Dental Representative at 1-888-703-6999.

LIBERTY Dental Forms

Member Satisfaction Survey
ADA Claim Form
HIPAA Authorization Medical\Dental Release Form		-  Spanish Version
Clinical Criteria and Practice Parameters
HIPAA Privacy Notice

Evidence of Coverage (EOC)

Covered California SHOP EOC Booklet		Spanish
Covered California Individual EOC Booklet		Spanish
Nevada Individual EOC Booklet		Spanish
LDP Individual EOC Booklet		Spanish
LDP Group EOC Booklet		Spanish
LDP Group EOC IHSS Public Authority Santa Clara

Medi-Cal

Beginning on July 1, 2017, you will be required to use your dental plan’s appeal procedures before you will be able to file for a state fair hearing. Federal law has changed and now requires this new process. You are not losing your right to a state fair hearing.

Los Angeles Prepaid Health Plan (PHP) EOC
PHP NOA Your Rights (Knox-Keene)

Other Languages:

Arabic		Armenian		Chinese
Farsi		Khmer		Korean
Russian		Spanish		Tagalog
Vietnamese

Sacramento Geographic Managed Care (GMC) EOC
GMC NOA Your Rights (Knox-Keene)

Other Languages:

Arabic		Chinese		Hmong
Russian		Spanish		Vietnamese

Grievance Forms

California Grievance Form		Spanish
California Grievance Form - Submit Online		Spanish
CA Request for Review of Cancellation, Rescission, or Nonrenewal
Nevada Grievance Form		Spanish
Missouri Grievance Form		Spanish
Florida Grievance Form		Spanish
All Other States Grievance Form		Spanish