SECTION 1: MEMBER INFORMATION  
Member last name  
Member first name  
Member date of birth  
_
___ / _____ / _____  
Member street address  
Member phone number  
City  
State  
ZIP Code  
Member identification number (see identification card)  
SECTION 2: INDIVIDUAL OR COMPANY AUTHORIZED TO RECEIVE MEMBER INFORMATION  
I am authorizing the individual or company named below to receive my information:  
Individual name (first and last name)  
Company name (if applicable)  
Street address  
City  
State  
ZIP Code  
Relationship to the Member (e.g., parent, spouse, domestic partner, adult child, insurance broker or agent, attorney, etc.)  
Purpose of the disclosure  
SECTION 3: MEMBER INFORMATION TO BE DISCLOSED  
I am authorizing the individual or company named in Section 2 to receive the following types of my information:  
All of my information (including, but not limited to, dental  
 Only the following types of my information (check all that apply)  
records, claims and information regarding eligibility, financial  
and billing, benefits, provider/dental office assignment, pre-  
treatment authorizations and specialty referrals, etc.  
 Eligibility information  
Benefits  
Claims  
Dental records (including x-rays)  
Provider/dental office assignment information  
Pre-treatment authorizations and specialty referrals  
Financial and billing information  
Other (please specify):  
SECTION 4: EXPIRATION OF AUTHORIZATION  
Unless I revoke my authorization in accordance with the procedures in Section 5, my authorization will expire on:  
Two (2) years from the date of my signature in Section 5  
OR  
 the earlier date of: ____ / _____ / _____  
SECTION 5: ACKNOWLEDGEMENT AND SIGNATURE  
By signing below, I hereby authorize LIBERTY Dental Plan and/or its affiliates or designees to disclose the types of information identified in Section 3 to the  
individual or company identified in Section 2. In addition, by signing below, I acknowledge and agree to the following:  
I have fully reviewed this Member Authorization Form (the “Form”), and I understand the contents of this Form. My authorization is being given voluntarily,  
and I understand that I can revoke my authorization at any time by providing written notice of my revocation to LIBERTY Dental Plan at (888) 703-6999 but  
that revocation of my authorization will not affect any action that has already been taken or any of my information that was released prior to LIBERTY Dental  
Plan’s receipt of written revocation. I further understand that information disclosed to the individual or company identified in Section 2 could be further  
disclosed by that individual or company and that the Health Insurance Portability and Accountability Act and/or privacy laws may no longer protect such  
information.  
Member signature: (must be age 18 or over)  
Print Member name:  
Date:  
____ / _____ / _____  
Parent signature: (IF member is a minor = age 17 or under)  
Print Parent name:  
Date:  
____ / _____ / _____  
PLEASE SEND COMPLETED FORM TO:  
3
40 Commerce, Suite 100, Irvine, CA 92602  
Or FAX to: 949-270-0101  
LDP_HIPAA_Auth_08-15_EN.docx