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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 PDF Icon
California Exchange Notice of Language Assistance Services PDF Icon
LIBERTY Dental Plan of Florida Notice of Language Assistance Services PDF Icon
Florida Exchange Notice of Language Assistance Services PDF Icon
LIBERTY Dental Plan of Missouri Notice of Language Assistance Services PDF Icon
LIBERTY Dental Plan of Nevada Notice of Language Assistance Services PDF 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
ADA Claim Form PDF Icon
HIPAA Authorization Medical\Dental Release FormPDF Icon   -  Spanish Version PDF Icon
Clinical Criteria and Practice Parameters PDF Icon
HIPAA Privacy Notice PDF Icon

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.

Evidence of Coverage (EOC)

California

Covered California SHOP EOC Booklet PDF Icon Spanish PDF Icon
Covered California Individual EOC Booklet PDF Icon Spanish PDF Icon
LDP Individual EOC Booklet PDF Icon Spanish PDF Icon
LDP Group EOC Booklet PDF Icon Spanish PDF Icon

Nevada

NV-100 through NV-1000 NV Commercial DHMO - EPO PDF Icon
Patriot NV-100 through Patriot NV-900NV Commercial Patriot Plan PDF Icon
Elite PPO, Signature PPONV Commercial PPO Plans PDF Icon
NV-500 POSNV Commercial Point of Sales Plans PDF Icon

Florida

Individual FL Individual Plans PDF Icon
Group FL Group Plans PDF Icon

Missouri

Missouri – EOC Booklet PDF 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
PHP NOA Your Rights (Knox-Keene) PDF Icon

Other Languages:
Sacramento Geographic Managed Care (GMC) EOC PDF Icon

Other Languages: