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Adult - Health Risk Assessment
Child - Health Risk Assessment
Coordination of Benefits
Email Authorization
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Formulario de autorización
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File a Grievance Spanish
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General Contact Us
FL Medicaid Home
Authorization for Release of Health Information
Enrollee Transfer Request
Health Risk Assessment
Adult - Health Risk Assessment - Spanish
Child - Health Risk Assessment - Spanish
Adult - Health Risk Assessment
Child - 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
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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
.
Complete un formulario para cada persona de su familia queesté inscrita en LIBERTY. Si tiene preguntas, llame LIBERTY al número gratuito 1.833.276.0850. Unrepresentante está disponible para hablar con usted de lunes a viernes, de 8:00 a. m. a 7:00 p. m. Losusuarios de TDD/TTY deben marcar el número 1.877.855.8039.
Completar este formulario es voluntario. No se le denegará atención en función de sus respuestas
confidenciales.
Last Date of Update 12/22/2021
Nombre del miembro:
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Apellido del miembro:
Required
Fecha de nacimiento:
Required
Please ensure your entry is valid.
Número de identificación de Medicaid:
Required
1. ¿El niño cuenta con hogar dental/recibe atención dental de manera frecuente?
Si
No
N/A
2. ¿El niño se cepilla los dientes diariamente?
Si
No
N/A
3. ¿Usted vive en un área con agua potable fluorada?
Si
No
N/A
4. ¿El niño come entre comidas?
Si
No
N/A
5. ¿El niño bebe refrescos, jugos o bebidas energizantes con frecuencia?
Si
No
N/A
6. ¿Es el inglés la lengua materna de su hijo?
Si
No
N/A
7. ¿El niño tiene caries?
Si
No
N/A
8. ¿La madre/cuidadora principal tiene caries activas?
Si
No
N/A
9. ¿El niño tiene necesidades especiales de salud?
Si
No
N/A
10. ¿El niño tiene placa en los dientes?
Si
No
N/A
11. ¿Se acuesta al niño con una botella que contiene azúcar natural o añadida?
Si
No
N/A
Entiendo que esta información se divulgará con mi nuevo plan dental.
Si
Si considera que necesita ver a un dentista antes de que LIBERTY se comunique con usted, comuníquese con su consultorio dental o busque atención en un hospital.
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