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Language Assistance Information | 語言協助信息 | Información sobre Asistencia en su Idioma

LIBERTY Dental Plan of California Notice of Language Assistance Services
California Exchange Notice of Language Assistance Services
LIBERTY Dental Plan of Florida Notice of Language Assistance Services
Florida Exchange Notice of Language Assistance Services
LIBERTY Dental Plan of Missouri Notice of Language Assistance Services
LIBERTY Dental Plan of Nevada Notice of Language Assistance Services
LIBERTY Dental Plan of New Jersey Notice of Language Assistance Services
LIBERTY Dental Plan of Oklahoma Notice of Language Assistance Services
 

For additional information, please call a LIBERTY Dental Representative
at 1-888-703-6999.


LIBERTY Dental Forms

(All forms available for download in PDF format)
Member Satisfaction Survey
ADA Claim Form
HIPAA Authorization Medical\Dental Release Form   -  Spanish Version
Clinical Criteria and Practice Parameters
HIPAA Privacy Notice

The materials provided to you are guidelines used by this Plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Member Handbooks & Evidence of Coverage (EOC)

California

LDP Individual EOC Booklet Spanish
LIBERTY Dental Plan CA Group EOC Booklet

Nevada

NV-100 through NV-1000 NV Commercial DHMO - EPO
Patriot NV-100 through Patriot NV-900NV Commercial Patriot Plan
Elite PPO, Signature PPONV Commercial PPO Plans
NV-500 POSNV Commercial Point of Sales Plans
LIBERTY Dental Plan NV Member Handbook Spanish

Florida

Individual FL Individual Plans
Group FL Group Plans
LIBERTY Dental Plan FL Member Handbook Spanish

Missouri

Missouri – EOC Booklet

Medi-Cal

Beginning on July 1, 2017, you will be required to use your dental plan’s appeal procedures before you will be able to file for a state fair hearing. Federal law has changed and now requires this new process. You are not losing your right to a state fair hearing.

Los Angeles Prepaid Health Plan (PHP) Member Handbook
PHP NOA Your Rights (Knox-Keene)

Other Languages:
Sacramento Geographic Managed Care (GMC) Member Handbook

Other Languages: