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LIBERTY Dental Plan Language Needs Survey

LIBERTY Dental Plan wants to provide effective communication and services to all its members. This includes persons with disabilities, and non-English speakers.

The purpose of this form is to gather information to help us serve you better.

Member Information

Your Language


How would you describe yourself? Check one or more below:

LIBERTY can communicate with persons who have disabilities in several ways. Check below to tell us how you would like to get information from the LIBERTY:

By checking this box, I confirm that I have read this form, or it has been read to me.