MEMBER INFORMATION (PLEASE PRINT)  
Member last name  
Member first name  
City  
Today’s date  
Member street address  
Member phone number  
State  
ZIP code  
Member identification number (see identification card)  
Employer or Group  
Patient name  
Relationship  
AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE PRINT)  
I am authorizing LIBERTY Dental Plan to allow the following person to act on my behalf during the grievance/appeals  
Representative last name  
Representative first name  
Representative phone number  
Representative Signature  
Member Signature  
DENTAL OFFICE/PROVIDER INFORMATION (PLEASE PRINT)  
I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from the  
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)  
Medicaid Appeals must be filed within 60 days from the date on your Denial Letter.  
Medicaid Grievances can be filed at any time.  
Medicare Appeals and Grievances must be filed within 60 days from the date on your Denial Letter or from the event  
that causes your dissatisfaction  
Commercial/Individual Appeals and Grievances much be filed within 180 days from the date on your Denial Letter or  
from the event that causes your dissatisfaction  
If you need help completing this form, please contact Member Services at 1-866-609-0418  
SUMMARY OF GRIEVANCE OR APPEAL  
Please share any information you have about your grievance or appeal. Please give us as many details as you can, if  
possible please provide the dates, names and any treatment. If needed you can attach an additional page.  
Please share with us how you would like to see your grievance or appeal resolved.  
Member Signature  
Date  
*
By providing LIBERTY with your signature, you are giving us your written permission to continue with the appeals process.  
If you do not sign and return this form, LIBERTY cannot continue with your appeal if it was received over the phone.  
PLEASE SEND COMPLETED SIGNED FORM TO:  
Or you may submit your grievance or appeal:  
LIBERTY Dental Plan of Nevada  
 By fax to LIBERTY’s Quality Management Department fax at (949) 270-0109  
Quality Management Department  Verbally by calling LIBERTY Dental Plan’s Member Services Department at toll-free  
P.O. Box 26110  
Santa Ana, CA 92602-26110  
number: (866) 703-6999, or TTY: (877) 855-8039  
 By using our website online grievance filing process by visiting  
You will receive a letter acknowledging receipt of your grievance or appeal within 5 calendar days of receipt by LIBERTY.  
You will receive a written resolution to your grievance or appeal within 30 calendar days of receipt by LIBERTY.  
CA G/A Form 201710  
pg. 2  
If you are not satisfied with LIBERTY's final decision, you may contact the Florida Department of Financial Services  
FDFS) in writing within 365 days of receipt of the final decision letter. You also have the right to contact FDFS at  
(
any time to inform them of an unresolved grievance.  
The Florida Department of Financial Services  
Consumer Complaints Division  
State Capitol Larson Building  
2
00 East Gaines Street, Room 637  
Tallahassee, Florida 32399-0300  
Telephone 1-800-342-2762  
CA G/A Form 201710  
pg. 3