File a Grievance or Appeal

Language Assistance Information | 語言協助信息 | 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

LIBERTY Dental Plan of New Jersey Notice of Language Assistance Services

LIBERTY Dental Plan of Oklahoma 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

Clinical Criteria and Practice Parameters

HIPAA Privacy Notice

HIPAA Authorization Medical\Dental Release Form

The materials provided to you are guidelines used by this Plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Member Handbooks & Evidence of Coverage (EOC)

California
LDP Individual EOC Booklet		Spanish
LIBERTY Dental Plan CA Group EOC Booklet		Spanish
Nevada
NV-100 through NV-1000 NV Commercial DHMO - EPO
Patriot NV-100 through Patriot NV-900NV Commercial Patriot Plan
Elite PPO, Signature PPONV Commercial PPO Plans
NV-500 POSNV Commercial Point of Sales Plans
LIBERTY Dental Plan NV Member Handbook		Spanish
Florida
Individual FL Individual Plans
Group FL Group Plans
LIBERTY Dental Plan FL Member Handbook		Spanish
Missouri
Missouri – EOC Booklet

Medi-Cal

Los Angeles Prepaid Health Plan (PHP) Member Handbook Spanish
Sacramento Geographic Managed Care (GMC) Member Handbook Spanish