Provider Complaint Form

Office/Provider Information

Patient/Member Information

Name:

Name:

Address:

Address:

Contact Person:

ID No.:

Phone:

DOB:

Fax:

Phone:

Select Reason for Your Complaint

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Plan Administration

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Provider Reimbursement

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Health Care Delivery

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Contracting

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Other

Fill out the form completely and make sure you keep a copy for your records. Send this form and all the necessary medical and/or dental documentation to support your complaint to the following:

LIBERTY Dental Plan, Attn: Grievances and Appeals, P.O. Box 15149, Tampa, FL 33684, or you can fax us at:

1-833-250-1816 or email us at: FLGandA@libertydentalplan.com

Explanation of Your Issue(s):

Your complaint will be processed once all necessary documentation is received. You will receive an acknowledgement letter within 3 business days of the receipt of your complaint by the Plan. You will receive a response letter to your complaint within 30 calendar days.

Failure to submit all supporting documentation may delay our response to your complaint. If your complaint includes multiple members/patients, list them all separately.

Contact your LIBERTY Network Manager for questions or concerns by calling us at 1-888-352-7924.

www.libertydentalplan.com

© 2018 LIBERTY Dental Plan FL_MD_Provider Complaint Form