   - CALIFORNIA
   LIBERTY Dental Plan (LIBERTY)
 LIBERTY 
    LIBERTY 


 

 
 
  




   

 

 
 
LIBERTY Dental Plan

 


  
 LIBERTY Dental Plan     
 
  
 
   



 
  

 Medicaid  

 Medicaid 
 Medicare  
  
   
  
CA G/A  2
   
888-703-6999 TTY 877-855-8039, 8:00 5:00 

 


  
  

LIBERTY Dental Plan of California
Grievances and Appeals Department
P.O. Box 26110
Santa Ana, CA 92602-26110
•
   LIBERTY
949-270-0109
• LIBERTY Dental Plan 888-703-6999,
TTY (877) 855-8039
•  
 www.libertydentalplan.com
• GandA@libertydentalplan.com
    
5
LIBERTY

   30
LIBERTY 
    
   
   
 
   
CA G/A  
   
   LIBERTY  LIBERTY 1-888-703-
6999   LIBERTY 

  
    
 LIBERTY  
30 , 
  (IMR) 
 IMR  IMR
 
  
   
     
 (1-888-HMO-2219)  TDD (1-877-688-9891)
    http://www.hmohelp.ca.gov
    IMR 
Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) follows State and Federal civil rights
laws. LIBERTY does not unlawfully discriminate, exclude people, or treat them differently because of sex, race,
color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability,
medical condition, genetic information, marital status, gender, gender identity, or sexual orientation.
LIBERTY provides:
• Free aids and services to people with disabilities to help them
communicate better, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible
electronic formats, other formats)
• Free language services to people whose primary language is not English,
such as:
Qualified interpreters
Information written in other languages
If you need these services, please contact us between 8 a.m. to 5 p.m (PST)
by calling (888) 703-6999. Or, if you cannot hear or speak well, please call
(800) 735-2929
HOW TO FILE A GRIEVANCE
If you believe that LIBERTY has failed to provide these services or unlawfully discriminated in another way on the
basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability,
physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual
CA G/A  4
orientation, you can file a grievance with LIBERTY’s Civil Rights Coordinator. You can file a grievance by phone,
in writing, in person, or electronically:
• By phone: Contact LIBERTY’s Civil Rights Coordinator, Monday through Friday, 8 a.m to 5 p.m (PST) by
calling 888-704-9833. Or if you cannot hear or speak well, please call (800) 735-2929.
• In writing: Fill out a complaint form or write a letter and send it to:
P.O. Box 26110
Santa Ana, CA 92799
• In person: Visit your doctor’s office or LIBERTY Dental Plan and say you want to file a grievance.
• Electronically: Visit LIBERTY Dental Plan website at https://www.libertydentalplan.com.
OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
You can also file a civil rights complaint with the California Department of Health Care Services, Office of Civil
Rights by phone, in writing, or electronically:
• By phone: Call 916-440-7370. If you cannot speak or hear well, please call 711 (Telecommunications
Relay Service).
• In writing: Fill out a complaint form or send a letter to:
Michele Villados
Deputy Director, Office of Civil Rights
Department of Health Care Services
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Complaint forms are available at http://www.dhcs.ca.gov/Pages/Language_Access.aspx.
• Electronically: Send an email to CivilRights@dhcs.ca.gov.
OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
If you believe you have been discriminated against on the basis of race, color, national origin, age, disability or sex,
you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights by phone, in writing, or electronically:
• By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD 1-800-537-7697.
• In writing: Fill out a complaint form or send a letter to:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Electronically: Visit the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
CA G/A  5
IMPORTANT: You can get an interpreter at no cost to talk to your dentist or dental plan. To get an interpreter or to
request written information (in your language or in a different format, such as Braille or larger font), first call your
Dental plan’s phone number at 1-888-703-6999. Someone who speaks (your language) can help you. If you need
more help, call the HMO Help Center at 1-888-466-2219.
IMPORTANTE: Puede obtener la ayuda de un intérprete sin costo alguno para hablar con su médico o con su
plan de salud. Para obtener la ayuda de un intérprete o pedir información escrita (en su idioma o en algún
formato diferente, como Braille o tipo de letra más grande), primero llame al número de teléfono de su plan de
salud al 1-888-703-6999. Alguien que habla español puede ayudarle. Si necesita ayuda adicional, llame al
Centro de ayuda de HMO al 1-888-466-2219. (Spanish)
重要提示﹕您與您的醫生或保健計劃工作人員交談時，可獲得免費口譯服務。如需口譯員服務或索取（用
給您的語言或布萊葉盲文或大字體等不同格式提供的）書面資料，請先打電話給您的保健計劃，電話號碼
1-888-703-6999。會講（您的語言）的人士將為您提供協助。 如需更多協助，請打電話給 HMO 協助中心，
電話號碼 1-888-466-2219。(Cantonese or Mandarin)
:مﺎھ ﺔﺑﻮﺘﻜﻣ تﺎﻣﻮﻠﻌﻣ ﺐﻠﻄﻟ وأ يرﻮﻓ ﻢﺟﺮﺘﻣ ﻰﻠﻋ لﻮﺼﺤﻠﻟ .ﺔﯿﺤﺼﻟا ﻚﺘﻄﺧ وأ ﻚﺒﯿﺒط ﻊﻣ ثﺪﺤﺘﻠﻟ
ً
ﺎﻧﺎﺠﻣ يرﻮﻓ ﻢﺟﺮﺘﻣ تﺎﻣﺪﺧ ﻰﻠﻋ لﻮﺼﺤﻟا ﻚﻨﻜﻤﯾ
ﻰﻠﻋ ﺔﯿﺤﺼﻟا ﺔﻄﺨﻟا ﻒﺗﺎھ ﻢﻗﺮﺑ
ً
ﻻوأ ﻞﺼﺗا ،(ﺮﯿﺒﻛ ﻂﺨﺑ وأ ﻞﯾاﺮﺑ ﺔﻘﯾﺮط ﻞﺜﻣ ،ىﺮﺧأ ﺔﻐﯿﺼﺑ وأ ﻚﺘﻐﻠﺑ)-888-703-69991 ﺎﻣ ﺺﺨﺷ كﺪﻋﺎﺴﯿﺳ .
(ﻚﺘﻐﻟ ﺲﻔﻧ) ثﺪﺤﺘﯾةﺪﻋﺎﺴﻣ ﺰﻛﺮﻤﺑ ﻞﺼﺗا ،ةﺪﻋﺎﺴﻤﻟا ﻦﻣ ﺪﯾﺰﻤﻟا ﺪﯾﺮﺗ ﺖﻨﻛ اذإ . HMO ﻢﻗﺮﻟا ﻰﻠﻋ-888-466-22191 (Arabic) .
ԿԱՐԵՎՈՐ ՏԵՂԵԿՈՒԹՅՈՒՆ. Դուք կարող եք խոսել Ձեր բժշկի կամ առողջապահական ծրագրի հետ՝
օգտվելով թարգմանչի ծառայություններից առանց որևէ վճարի: Թարգմանիչ ունենալու կամ գրավոր
տեղեկություն խնդրելու համար (հայերենով կամ մեկ այլ ձևաչափով, օրինակ՝ Բրայլը կամ մեծ
տառաչափը), նախ զանգահարեք առողջապահական ծրագրի հեռախոսահամարով՝ 1-888-703-6999:
Ցանկացած մեկը, ով խոսում է հայերեն, կարող է օգնել Ձեզ: Եթե Ձեզ լրացուցիչ օգնություն է
անհրաժեշտ, ապա զանգահարեք Առողջապահական օժանդակության կազմակերպության (HMO)
Օգնության կենտրոն՝ 1-888-466-2219 հեռախոսահամարով: (Armenian)
::  
   
  --
-
 ---
:ﻢﮭﻣ یاﺮﺑ ﺎﯾ یرﻮﻀﺣ ﻢﺟﺮﺘﻣ ﺖﺳاﻮﺧرد یاﺮﺑ .ﺪﯿﺷﺎﺑ ﮫﺘﺷاد یرﻮﻀﺣ ﻢﺟﺮﺘﻣ نﺎﮕﯾار رﻮﻄﺑ ﺪﯿﻧاﻮﺗ ﯽﻣ ﮫﻤﯿﺑ حﺮط ﺎﯾ ﺞﻟﺎﻌﻣ ﮏﺷﺰﭘ ﺎﺑ ﻮﮕﺘﻔﮔ یاﺮﺑ
ﯽﻨﻌﯾ دﻮﺧ حﺮط ﻦﻔﻠﺗ هرﺎﻤﺷ ﺎﺑ اﺪﺘﺑا (ﺖﺷرد پﺎﭼ ﺎﯾ ﻞﯾﺮﺑ ﺪﻨﻧﺎﻣ ﺮﮕﯾد یﺎھ ﺖﻣﺮﻓ ﺎﺑ ﺎﯾ ،دﻮﺧ نﺎﺑز ﮫﺑ) ﯽﺒﺘﮐ ترﻮﺼﺑ تﺎﻋﻼطا ﺖﻓﺎﯾرد
1-888-703-6999 سﺎﻤﺗ ﺰﮐﺮﻣ ﺎﺑ ﺪﯾراد زﺎﯿﻧ ﺮﺘﺸﯿﺑ ﮏﻤﮐ ﮫﺑ ﺮﮔا .ﺪھد یرﺎﯾ ار ﺎﻤﺷ ﺪﻧاﻮﺗ ﯽﻣ ،ﺪﻨﮐ ﯽﻣ ﺖﺒﺤﺻ (ار ﺎﻤﺷ نﺎﺑز) ﮫﮐ یدﺮﻓ .ﺪﯿﯾﺎﻤﻧ ﻞﺻﺎﺣ
وا ما چا ﯽﻧﺎﺳر ﮏﻤﮐ(HMO) هرﺎﻤﺷ ﮫﺑ1-888-466-2219 .ﺪﯿﯾﺎﻤﻧ ﻞﺻﺎﺣ سﺎﻤﺗ (Farsi)
TSEEM CEEB: Muaj tus neeg txhais lus pub dawb rau koj kom koj tham tau nrog koj tus kws kho mob los yog
nrog lub chaw pab them nqi kho mob rau koj. Yog xav tau ib tug neeg txhais lus los yog xav tau cov ntaub ntawv
(sau ua koj yam lus los sis ua lwm yam ntawv, zoo li ua lus Braille los sis ua ntawv loj loj), xub hu rau koj lub chaw
pab them nqi kho mob tus xov tooj ntawm 1-888-703-6999. Yuav muaj ib tug neeg hais lus Hmoob pab tau koj.
Yog koj xav tau kev pab ntxiv, hu rau HMO Qhov Chaw Txais Tos Pab Neeg ntawm
1-888-466-2219. (Hmong)
중요: 의사나 건강 플랜과 대화하실 때 무료 통역 서비스를 받으실 수 있습니다. 통역을 구하시거나 문자
정보(한국어 번역본 또는 점자나 큰 글자 같이 다른 형식으로 된 정보)를 요청하시려면, 가입하신 건강
플랜에 1-888-703-6999로 먼저 전화하십시오. 한국어를 하는 사람이 도와드릴 수 있습니다. 도움이 더
필요하시면 HMO 도움 센터에 1-888-466-2219로 연락하십시오. (Korean)
CA G/A  
ВАЖНО: Вы можете бесплатно воспользоваться услугами переводчика во время обращения к врачу или в
страховой план. Чтобы запросить услуги переводчика или письменную информацию (на русском языке или
в другом формате, например, шрифтом Брайля или крупным шрифтом), позвоните в свой страховой план по
телефону 1-888-703-6999. Вам окажет помощь русскоговорящий сотрудник. Если вам нужна помощь в
других вопросах, позвоните в справочный центр Организации медицинского обеспечения (HMO) по
телефону 1-888-466-2219. (Russian)
MAHALAGA: Maaari kang kumuha ng isang tagasalin nang walang bayad upang makipag-usap sa iyong doktor o
planong pangkalusugan. Upang makakuha ng isang tagasalin o upang humiling ng nakasulat na impormasyon (sa
iyong wika o sa ibang anyo, tulad ng Braille o malalaking letra), tawagan muna ang numero ng telepono ng iyong
planong pangkalusugan sa 1-888-703-6999. Ang isang tao na nakapagsasalita ng Tagalog ay maaaring tumulong sa
iyo. Kung kailangan mo ng karagdagang tulong, tawagan ang Sentro ng Pagtulong ng HMO sa 1-888-466-2219.
(Tagalog)
LƯU Ý QUAN TRỌNG: Quý vị có thể được cấp dịch vụ thông dịch miễn phí khi đi khám tại văn phòng bác sĩ
hoặc khi cần liên lạc với chương trình bảo hiểm sức khỏe của quý vị. Để được cấp dịch vụ thông dịch hoặc yêu cầu
văn bản thông tin bằng tiếng Việt hoặc bằng một hình thức khác như chữ nổi hoặc bản in bằng chữ khổ lớn, trước
tiên hãy gọi số điện thoại của chương trình bảo hiểm sức khỏe của quý vị tại 1-888-703-6999. Sẽ có người nói tiếng
Việt giúp đỡ quý vị. Nếu quý vị cần được giúp đỡ thêm, vui lòng gọi Trung tâm Hỗ trợ HMO theo số 1-888-466-
2219. (Vietnamese)
ਮਹੱ ਤਵਪੂਰਨ:               |   
   (      ,       )    ,  1-888-
703-6999 ‘       ‘  |   ( )  ,    
 |       ,  1-888-466-2219 ‘ HMO Help Center (...  )
  | (Punjabi)
重要 通訳を通して医師や医療保険会社とお話しいただけます。料金はかかりません。日本語でサポートを受け
たり、日本語で書かれた情報を入手するには、あなたの医療保険会社（1-888-703-6999）までお電話ください。日
本語が話せるスタッフがお手伝いします。さらなるサポートが必要な場合は、HMO Help Center （1-888-466-
2219）までお電話ください。(Japanese)
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ອ HMO ຕາມໝາຍເລກ 1-888-466-2219. (Lao)
  :           
       
             (       ,  
(Braile)   )),        1-888-703-6999     (   ),
           ,  (HMO)    1-888-466-
2219    ( Hindi)
เร ื
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องสําค ัญ:  



 (

)  
 1-888-703-6999

 
 
 HMO

 1-888-466-2219. (Thai)