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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 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)

California

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

Nevada

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

Florida

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

Missouri

Missouri – EOC Booklet PDF IconHTML 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

Other Languages:

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