WRITTEN MEMBER GRIEVANCE AND APPEAL FORM – NEVADA
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
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)
Appeals must be filed within 90 days from
the date on your Notice of Action
Denial Letter)
(
Grievances can be filed at any time.
If you need help completing this form, please contact Member Services at 1-866-609-0418
