MEMBER INFORMATION  
Member last name  
Member first name  
Today’s date  
Member street address  
Member phone number  
Employer or Group  
City  
State  
ZIP code  
Member identification number (see identification card)  
Patient name  
Relationship  
DENTAL OFFICE/PROVIDER INFORMATION  
I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from the following office:  
Office number Dental office name Date of last visit  
Dental office street address  
Dental office phone number  
City  
State  
ZIP Code  
Name(s) of dental office staff involved (if known)  
Description of Grievance  
Describe your grievance in detail. Please provide the dates, names and treatment that are the subject of your grievance. Attach additional pages, if necessary.  
Description of Grievance  
Describe your grievance in detail. Please provide the dates, names and treatment that are the subject of your grievance. Attach additional pages, if necessary.  
What is your desired resolution to your concern(s)?  
MEMBERS OF LIBERTY DENTAL PLAN ONLY - PLEASE SEND COMPLETED FORM TO:  
Or you may submit your grievance:  
LIBERTY Dental Plan  
Attention: Quality Management Department  
P.O. Box 26110  
 By fax to LIBERTY’s Member Services Department fax at (949) 223-0011, or  
 Verbally by calling LIBERTY Dental Plan’s Member Services Department at toll-free number: (888) 703-6999, or  
 By using our website online grievance filing process by visiting www.libertydentalplan.com.  
Santa Ana, CA 92799-6110  
You will receive a letter acknowledging receipt of your grievance within five (5) calendar days of receipt by LIBERTY.  
You will receive a written resolution to your grievance within thirty (30) calendar days of receipt by LIBERTY.  
IF YOUR HEALTH PLAN CONTRACTS WITH LIBERTY TO PROVIDE YOUR DENTAL BENEFITS:  
You should contact your Health Plan for information on how to submit a grievance or appeal, or you may contact LIBERTY Dental Plan.  
When contacting LIBERTY to inquire on how to submit a grievance or appeal, please call (888) 703-6999.  
If your Health Plan allows, LIBERTY may accept your grievance or appeal verbally.  
If your Health Plan allows, LIBERTY may accept this completed form as your written grievance or appeal.  
A LIBERTY Member Services Representative will let you know if your Health Plan requires that you contact them directly to file a grievance or appeal regarding your  
dental treatment and/or services.  
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