Forms & Literature

LIBERTY Dental Forms

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

Evidence of Coverage (EOC)

• Covered California SHOP EOC Booklet  - Spanish Version
• Covered California Individual EOC Booklet  - Spanish Version
• LDP Individual EOC Booklet  - Spanish Version
• LDP Group EOC Booklet - Spanish Version
• 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)
  Sacramento Geographic Managed Care (GMC) EOC	GMC NOA Your Rights (Knox-Keene)

Grievance Forms

• California Grievance Form   -   Spanish Version
  or submit online: English Online Form - Spanish Online Form
  
  
• Nevada Grievance Form   -   Spanish Version
• Missouri Grievance Form   -   Spanish Version
• Florida Grievance Form   -   Spanish Version
• All Other States Grievance Form   -   Spanish Version

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

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