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Forms & Literature

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

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

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


LIBERTY Dental Forms

(All forms available for download in PDF format)
Member Satisfaction Survey PDF Icon HTML Icon
ADA Claim Form PDF Icon HTML Icon
HIPAA Authorization Medical\Dental Release FormPDF Icon HTML Icon   -  Spanish Version PDF Icon HTML Icon
Clinical Criteria and Practice Parameters PDF Icon HTML Icon
HIPAA Privacy Notice PDF Icon HTML Icon

Evidence of Coverage (EOC)

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

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 PDF Icon HTML Icon
PHP NOA Your Rights (Knox-Keene) PDF Icon HTML Icon

Other Languages:
Sacramento Geographic Managed Care (GMC) EOC PDF Icon HTML Icon
GMC NOA Your Rights (Knox-Keene) PDF Icon HTML Icon

Other Languages:

Grievance Forms

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