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LIBERTY Dental Plan Provider Compliance Attestation


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

  1. CMS Compliance & FWA Training. Provider distributes General Compliance and FWA training (LIBERTY’s or Provider’s own training, if comparable to LIBERTY’s) to all Provider employees and other personnel who support LIBERTY Government Business, within 30 days of hire/contract and annually thereafter. To access LIBERTY’s training, visit www.libertydentalplan.com.

  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 30 days of hire/contract and annually thereafter. To access LIBERTY’s training, visit www.libertydentalplan.com.

  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, CLAS, Section 1557 & Critical Incident trainings (LIBERTY’s or Provider’s own training, if comparable to LIBERTY’s) within 30 days of hire/contract and annually thereafter. To access LIBERTY's training, visit www.libertydentalplan.com.

  4. HIPAA (Privacy & Security). Provider distributes comprehensive HIPAA Privacy & Security training (LIBERTY’s or Provider’s own training, if comparable to LIBERTY’s) to all Provider employees and other personnel who support LIBERTY Government Business, within 30 days of hire/contract and annually thereafter. To access LIBERTY’s training, visit www.libertydentalplan.com.

  5. 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

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