WRITTEN MEMBER GRIEVANCE AND APPEAL FORM – FLORIDA
Please use this form to help file a grievance or appeal with LIBERTY Dental Plan
(
LIBERTY). If you are filing an appeal, you must sign and complete this form and
return it to LIBERTY within 15 days from the date you received it .
MEMBER INFORMATION (PLEASE PRINT)
Member last name
Member first name
City
Today’s date
Member street address
Member phone number
State
ZIP code
Member identification number (see identification card)
Employer or Group
Patient name
Relationship
AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE PRINT)
I am authorizing LIBERTY Dental Plan to allow the following person to act on my behalf during the grievance/appeals
Representative last name
Representative first name
Representative phone number
Representative Signature
Member Signature
DENTAL OFFICE/PROVIDER INFORMATION (PLEASE PRINT)
I am authorizing LIBERTY Dental Plan to request my information, including chart records and x-rays, if applicable, from the
Office number Dental office name Date of last visit
Dental office street address
Dental office phone number
City
State
ZIP Code
Name(s) of dental office staff involved (if known)
Medicaid Appeals must be filed within 60 days from the date on your Denial Letter.
Medicaid Grievances can be filed at any time.
Medicare Appeals and Grievances must be filed within 60 days from the date on your Denial Letter or from the event
that causes your dissatisfaction
Commercial/Individual Appeals and Grievances much be filed within 180 days from the date on your Denial Letter or
from the event that causes your dissatisfaction
If you need help completing this form, please contact Member Services at 1-866-609-0418
