Forms and plan documents
Find the information you need to help you understand your plan. If you need assistance or another format (for example: another language, audio, large print, braille) please contact us.
Browse forms and plan documents by language
Note: Not all forms and plan documents are available in all languages.
National forms and plan documents
- ADA dental claim form
- HIPAA notice of privacy practices
- Liberty Dental Plan non-discrimination notice
- National clinical criteria guidelines and practice parameters
- Authorization to disclose protected health information (PHI)
- National notice of language assistance services
- National authorization of representative (AOR) form (English)
State forms and plan documents
California
Florida
Nevada
Need to file a grievance or appeal?
The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.