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Forms & Literature

LIBERTY Dental Forms

(All forms available for download in PDF format)

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


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 Online
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

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

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