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)?  
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 Quality Management Department fax at (949) 270-0109, 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 you have a grievance against your Health Plan, you should first telephone your Health Plan at 1-888-902-0407  
and use your Health Plan’s grievance process before contacting the Missouri Department of Insurance. Utilizing  
this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If  
you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by  
your Health Plan, or a grievance that remained unresolved for more than 30 days, you may call the Department of  
Insurance for assistance. You may also be eligible for external review for an impartial review of medical decisions  
made by a Health Plan related to the medical necessity of a proposed service or treatment, coverage decisions for  
treatments that are experimental or investigational in nature and payment disputes for emergency or urgent  
medical services. Also, you may directly contact the Missouri Department of Insurance, Financial Institutions and  
Professional Registration (“MDI”). MDI has established a process to receive inquiries and complaints from  
consumers of healthcare in Missouri concerning healthcare plans. For More Information Contact MDI’s Consumer  
Hotline: 1-800-726-7390. Inquiries and complaints may be faxed to Fax Number: 573-526-4898, filed online at:  
http://insurance.mo.gov/consumers/complaints/index.php or mailed to:  
Missouri DIFP  
Attn: Consumer Affairs  
P.O. Box 690  
Jefferson City, MO 65102-0690  
IMPORTANT: Can you read this document? If not, we can have somebody help you read it. You may also be able to  
get this letter written in your language. For free help, please call right away at 1-888-703-6999.  
Spanish (Español)  
IMPORTANTE: ¿Puede leer esta noticia? Si no, alguien le puede ayudar a leerla. Además, es posible que reciba esta  
noticia escrita en su propio idioma. Para obtener ayuda gratuita, llame ahora mismo al 1-888-703-6999.  
LDP_GR_FORM_MO_2015.09.07.docx  
pg. 2