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LIBERTY Dental Plan Provider Compliance Attestation

I certify that I am an authorized representative of the Provider named above, for all locations listed above, and confirm the following representations are true, based upon current information and reasonable belief:

  1. CMS Compliance & FWA Training. Provider complies with all Centers for Medicare and Medicaid Services (CMS) General Compliance and Fraud Waste and Abuse (FWA) training requirements, including ensuring that all Provider employees and other personnel who support LIBERTY business, including LIBERTY’s Plan Partners’ Medicare Advantage, Medicare-Medicaid (Duals), and/or Medicaid business (“LIBERTY Government Business”) receive both General Compliance and FWA training within 90 days of hire, and annually thereafter, utilizing one or more of the following methods:
  2. Code of Conduct. Provider distributes a Code of Conduct (LIBERTY’s or Provider’s own Code of Conduct, if comparable to LIBERTY’s) * to all Provider employees and other personnel who support LIBERTY Government Business, within 90 days of hire and annually thereafter.
    • Provider distributes LIBERTY’s Code of Conduct located at
    • Provider distributes its own Code of Conduct, which is comparable to LIBERTY’s.
  3. Cultural Competency & Critical Incident Training. Provider ensures all Provider employees and other personnel who support LIBERTY’s Government Business. Complete LIBERTY’s Cultural Competency & Critical Incident trainings within 90 days of hire and annually thereafter. To access the training, visit and select Providers.
  4. Record Retention. Provider maintains supporting documentation for a period of ten (10) years after training completion, and Code of Conduct dissemination, for all Provider employees and other personnel supporting LIBERTY Government Business, and can furnish the documentation upon request.

*Note: LIBERTY is required to communicate, through dissemination of LIBERTY’s Code of Conduct, its commitment to conducting business in an ethical manner, and consistent with governing law and program requirements. LIBERTY will also accept the dissemination of Provider’s comparable Code of Conduct to fulfill this requirement.

Associates and Staff

List of the associates and staff that have completed the annual compliance training

 Office IDOffice NameStaff NameStaff TitleNPI

Please click Submit only once