Child - Health Risk Assessment

Secure Email Grievance Forms

Language Translation

Member Group Dental Office Office Vendor

Members
Welcome to Member Services!Find a Dentist Community Smiles Program Member COVID-19 Resources Group & Plan Partner Sites LIBERTY Dental Plan Language Needs Survey Oral Health & Wellness Tips FAQs File a Grievance or Appeal Forms & Literature Medi-Cal Member - Contact Us
Providers
Providers Disclosure of Ownership & Control Interest Form Requirements Contract With Us Join Our Network Provider Portal Registration Value-Based Program (VBP)Secure Email Portal Provider Resource Library Directory Information Validation (DIV)Provider TeleDentistry Resources Provider COVID-19 Resources Clinical Criteria Guidelines & Practice Parameters Provider Compliance Training Florida Medicaid Webinar Americans with Disabilities Act (ADA) Survey Frequently Asked Questions Secured Documents Self Service Tools Provider Newsletters Providers - Contact Us
Brokers
Welcome Request a Quote California Application Missouri Application Nevada Application All Other States Agents & Brokers - Contact Us
Programs
Medicaid Medi-Cal Medicare Advantage Commercial Individual & Family Plans Request a Quote
State Sites
California Florida Hawaii Illinois Missouri Nevada New Jersey New York Oklahoma Texas All Other States
Find a Dentist
About LIBERTY
About LIBERTY Careers Compliance News & Events Privacy Contact Us

Health Risk Assessment

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

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. Child has a dental home/receives regular dental care?

Yes

N/A

2. Child has teeth brushed daily?

Yes

N/A

3. Do you live in an area with fluoridated drinking water?

Yes

N/A

4. Does child snack between meals?

Yes

N/A

5. Child often drinks soda, juices, or energy drinks?

Yes

N/A

6. Is English your child’s primary language?

Yes

N/A

7. Child has cavities?

Yes

N/A

8. Mother/primary caregiver has active cavities?

Yes

N/A

9. Child has special health care needs?

Yes

N/A

10. Child has plaque on teeth?

Yes

N/A

11. Child is put to bed with a bottle containing natural or added sugar?

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

Submission Success

EXPLORE

Members
Providers
Brokers

PROGRAMS

Medicaid
Medi-Cal
Commercial
Individual & Family Plans
Get a Quote

ABOUT

Overview
Careers
Compliance
News and Events
Interoperability API
Contact Us

MEMBER RESOURCES

Contact Member Services
Find a Dentist
Member Login

Nondiscrimination and Language Assistance