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LIBERTY Dental Plan Language Needs Survey


LIBERTY Dental Plan wants to provide effective communication and services to all its members. This includes persons with disabilities, and non-English speakers.

The purpose of this form is to gather information to help us serve you better.

Member Information


Your Language














Race/Ethnicity

How would you describe yourself? Check one or more below:






LIBERTY can communicate with persons who have disabilities in several ways. Check below to tell us how you would like to get information from the LIBERTY:









By checking this box, I confirm that I have read this form, or it has been read to me.