Adult - Health Risk Assessment

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Health Risk Assessment

FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Coordination of Benefits
Email Authorization
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Formulario de autorización
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FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Coordination of Benefits
Email Authorization
Enroll in a Healthy Behavior Program
Formulario de autorización
File a Grievance or Appeal
File a Grievance Spanish
Leave Feedback & Suggestions
Update Contact Info
General Contact Us

FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Coordination of Benefits
Email Authorization
Enroll in a Healthy Behavior Program
Formulario de autorización
File a Grievance or Appeal
File a Grievance Spanish
Leave Feedback & Suggestions
Update Contact Info
General Contact Us

2017
HITRUST Certified

LIBERTY received HITRUST CSF v8.1 certified status for its Health Solutions Plus core application and supporting systems as of 11/20/17

2018
HEDIS NCQA Certified

LIBERTY Dental Plan was presented with a

2018 NCQA-Certified HEDIS^® Compliance Audit™

by AttestHealth Care Advisors, LLC, an NCQA certified audit group.

NCQA has reviewed and accredited LIBERTY’s Credentialing and Utilization Management functions only. For complete details on the scope of this review, visit www.ncqa.org.

Please Complete one form for each person in your family who is enrolled in LIBERTY. If you have questions, please call LIBERTY, toll free at 1.833.276.0850. A representative is available to speak with you Monday through Friday, between 8:00 am and 7:00 pm. TDD/TTY users should dial 1.877.855-8039.

Filling out this form is voluntary. You will not be denied care based on your confidential answers.

Last Date of Update 12/22/2021

Member's First Name:

Required

Member's Last Name:

Required

Date of Birth:

RequiredPlease ensure your entry is valid.

Medicaid ID Number:

Required

1. Has it been more than 12 months since your last dental visit?

Yes

N/A

2. Do you have pain when eating cold, hot, or sugary foods?

Yes

N/A

3. Do you have painful tooth eruption?

Yes

N/A

4. Do you have an infected tooth or teeth?

Yes

N/A

5. Do you have a broken tooth or teeth?

Yes

N/A

6. Is your mouth dry?

Yes

N/A

7. Do your gums bleed when you brush or floss?

Yes

N/A

8. Have you had any gum (periodontal) treatments?

Yes

N/A

Date of last treatment:

Please ensure your entry is valid.

9. Do you wear dentures or partials?

Yes

N/A

10. Are you currently receiving radiation or chemotherapy?

Yes

N/A

11. Are you pregnant?

Yes

N/A

12. Do you see a doctor regularly for a chronic medical condition?

Yes

N/A

Check all that apply:

Cancer

Diabetes

Kidney Disease

Other

13. Do you have or associate yourself with a mental or physical disability?

Yes

N/A

I understand that this information will be disclosed to my new dental plan.

Yes

If you think you need to see a dentist before LIBERTY contacts you, please contact your dental office or seek care from a hospital.

Please only click Submit once

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