LIBERTY’S FLORIDA MEDICAID DENTAL HEALTH PROGRAM
MEMBER HANDBOOK
Have Questions? Visit us at:
www.libertydentalplan.com/FLMedicaid
Call us at
LIBERTY Dental Plan of Florida, Inc.
Making members shine, one
smile at a timeTM
Questions? Call Member Services at |
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Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) complies with all applicable Federal civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin, age, disability, or sex.
LIBERTY provides free aids and services to people with disabilities, and free language services to people whose primary language is not English, such as:
•Qualified interpreters, including sign language interpreters
•Written information in other languages and formats, including large print, audio, accessible electronic formats, etc.
If you need these services, please contact us Monday through Friday, 8:00 a.m. to 8:00 p.m. at:
LIBERTY brinda ayuda y servicios gratuitos a personas con discapacidades, y servicios de idioma gratuitos a personas cuyo idioma materno no es el inglés, como por ejemplo:
•Intérpretes calificados, incluso intérpretes del lenguaje de señas
•Información escrita en otros idiomas y formatos, incluso en letra grande, audio, formatos electrónicos accesibles, etc.
Si necesita estos servicios, comuníquese con nosotros al
LIBERTY offre des matériels et services d’assistance aux personnes handicapées et des services gratuits d’interprétation et de traduction aux personnes dont la langue maternelle n’est pas l’anglais, notamment des services:
•d’interprètes, y compris des services d’interprètes de langage gestuel
•d’information écrite dans d’autres langues et formats, y compris des services d’impression en gros caractères, des services audio, des services en formats électroniques d’accessibilité, etc.
Si vous avez besoin de ces services, veuillez communiquer avec nous au
LIBERTY ofri moun ki gen andikap sèvis epi èd ki gratis, epi li ofri moun ki pa gen anglè kòm lang manman yo sèvis lang gratis tankou:
•Entèprèt kalifye, kòm entèprèt pou lang siy.
•Enfòmasyon ekri nan lòt lang ak sou lòt fòma, tankou lèt laj, odyo, fòma ki aksesib elektwonikman, etc.
Si w bezwen sèvis sa yo, tanpri sonnen nou nan nimewo
Questions? Call Member Services at |
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LIBERTY fornisce assistenza e servizi gratuiti alle persone con disabilità e servizi linguistici gratuiti alle persone che abitualmente utilizzano una lingua diversa dall'inglese, ad esempio:
•Interpreti qualificati, inclusi quelli specializzati nella lingua dei segni.
•Informazioni scritte in altre lingue e in altri formati, quali stampa a caratteri grandi, audio, formati elettronici accessibili, ecc.
Se hai bisogno di questi servizi, contattaci ai seguenti numeri:
Компания LIBERTY предоставляет бесплатные специализированные материалы и услуги лицам с ограниченными возможностями здоровья и бесплатные услуги перевода тем, для кого английский не является основным языком общения, в том числе:
•услуги квалифицированных переводчиков и сурдопереводчиков;
•письменную информацию на других языках и в других форматах (напечатанную крупным шрифтом, в виде аудиозаписи, в доступных электронных форматах и др.)
Если вы нуждаетесь в данных услугах, обращайтесь к нам по телефону
If you believe LIBERTY has failed to provide these services or has discriminated on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with LIBERTY’s Civil Rights Coordinator:
•Phone:
•TTY:
•Fax:
•Email: compliance@libertydentalplan.com
•Online:
If you need help filing a grievance, LIBERTY’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201
Online at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Questions? Call Member Services at |
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“If you do not speak English, call us at
Spanish: Si usted no habla inglés, llámenos al
French: Si vous ne parlez pas anglais,
Haitian Creole: Si ou pa pale lang Anglè, rele nou
TTY. Nou ka jwenn sèvis entèprèt pou ou, epitou nou kapab ede reponn kesyon ou yo nan lang ou pale a. Nou kapab ede ou jwenn yon pwofesyonèl swen sante ki kapab kominike avèk ou nan lang ou pale a."
Italian: "Se non parli inglese chiamaci al
Russian: «Если вы не разговариваете
This information is available for free in other formats. Please contact our customer service number at 1-
Questions? Call Member Services at |
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Important Contact Information
You can contact |
Where |
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Member Help Line TTY |
Available 24 hours |
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Website |
www.libertydentalplan.com/FLMedicaid |
Available 24 hours |
Office Address |
7870 Woodland Center Blvd. Tampa, |
Monday - Friday |
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FL 33614 |
8:00 a.m. to 5:00 p.m. |
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Member Helpline |
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Questions? Call Member Services at |
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Questions? Call Member Services at |
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Welcome to LIBERTY Dental Plan
LIBERTY Dental Plan (LIBERTY) has a contract with the Florida Agency for Health Care Administration to provide dental services to people with Medicaid. This is called the Florida Dental Health Program (DHP). You are enrolled in our dental health plan. This means that we will offer you Medicaid dental services. We work with a group of dental providers to help meet your dental needs.
This handbook will be your guide for all dental services available to you. You can ask us any questions, or get help making appointments. If you need to speak with us, just call us at
Section 1: Your Health Plan Dental Identification Card (ID card)
You should have received your dental ID card in the mail. Call us if you have not received your card or if the information on your card is wrong. Each member of your family in our plan should have their own dental ID card.
Carry your dental ID card at all times and show it each time you go to a dental appointment. Never give your dental ID card to anyone else to use. If your dental ID card is lost or stolen, call us so we can give you a new dental ID card.
Your dental ID card will look like this:
Questions? Call Member Services at |
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Section 2: Your Privacy
Your privacy is important to us. You have rights when it comes to protecting your health information, such as your name, Plan identification number, race, ethnicity, and other things that identify you. We will not share any health information about you that is not allowed by law.
If you have any questions, call Member Services. Our privacy policies and protections are:
A statement describing LIBERTY’s policies and procedures for preserving the confidentiality of dental records is available and will be furnished to you upon request.
As required by law, this notice is about your rights, our legal duties and privacy practices with respect to the privacy of Personal Health Information (PHI). This notice also talks about the way we may collect, use and disclose your PHI. We must follow the orders of the notice currently in effect. We keep the right to make changes to this notice from time to time and to make the changed notice effective for all PHI we keep. You can find our most current privacy notice our website at https://www.libertydentalplan.com /About- LIBERTY-
Call our Member Services at
Questions? Call Member Services at |
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Section 3: Getting Help from the Member Services
Our Member Services Department can answer all of your questions. We can help you choose or change your Primary Dental Provider (PDP for short), find out if a service is covered, get referrals, find a provider, replace a lost ID card, help update your address and explain any changes that might affect you or your family’s benefits.
Contacting Member Services
You may call us at
Contacting Member Services after Hours
Our staff and dentists are available
TTY
Section 4: Do You Need Help Communicating?
If you do not speak English, we can help. We have people who help us talk to you in your language. We provide this help for free.
For people with disabilities: If you use a wheelchair, or are blind, or have trouble hearing or understanding, call us if you need extra help. We can tell you if a provider’s office is wheelchair accessible or has devices for communication. Also, we have services like:
•Florida Relay. Call 711 to receive assistance communicating with standard (voice) telephone users.
•Telecommunications Relay Service. This helps people who have trouble hearing or talking to make phone calls. Call
•Information and materials in large print, audio (sound); and braille
•Help in making or getting to appointments
•Names and addresses of providers who specialize in your disability
All of these services are provided free to you.
Section 5: When Your Information Changes
If any of your personal information changes, let us know as soon as possible. You can do so by calling Member Services. We need to be able to reach you about your health care needs.
Questions? Call Member Services at |
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The Department of Children and Families (DCF) needs to know when your name, address, county, or telephone number changes as well. Call DCF toll free at
Section 6: Your Medicaid Eligibility
In order for you to go to your dental appointments and for LIBERTY to pay for your services, you have to be covered by Medicaid and enrolled in our plan. This is called having Medicaid eligibility. DCF decides if someone qualifies for Medicaid.
Sometimes things in your life might change, and these changes can affect whether or not you can still have Medicaid. It is very important to make sure that you have Medicaid before you go to any appointments. Just because you have a Plan ID Card does not mean that you still have Medicaid. Do not worry! If you think your Medicaid has changed or if you have any questions about your Medicaid, call our Member Services Department and we can help you check on it.
If you Lose your Medicaid Eligibility
If you lose your Medicaid and get it back within 180 days, you will be enrolled back into our plan.
If you have Medicare
If you have Medicare, continue to use your Medicare ID card when you need medical services (like going to the doctor or the hospital), but also give the provider your Medicaid Plan ID card too.
If you are having a baby
If you have a baby, he or she will be covered by us on the date of birth. Call Member Services to let us know that your baby has arrived and we will help make sure your baby is covered and has Medicaid right away.
It is helpful if you let us know that you are pregnant before your baby is born to make sure that your baby has Medicaid. Call DCF toll free at
Questions? Call Member Services at |
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Section 7: Enrollment in Our Plan
When you first join our plan, you have 120 days to try our plan. If you do not like it for any reason, you can enroll in another dental plan. Once those 120 days are over, you are enrolled in our plan for the rest of the year. This is called being
Open Enrollment
Open enrollment is a period that starts 60 days before the end of your year in our plan. The State’s Enrollment Broker will send you a letter letting you know that you can change plans if you want. This is called your Open Enrollment period. You do not have to change plans. If you leave our plan and enroll in a new one, you will start with your new plan at the end of your year in our plan. Once you are enrolled in the new plan, you will have another 60 days to decide if you want to stay in that plan or change to a new one before you are
Section 8: Leaving Our Plan (Disenrollment)
Leaving a plan is called disenrolling. If you want to leave our plan while you are locked- in, you have to call the State’s Enrollment Broker. By law, people cannot leave or change plans while they are
You can leave our plan at any time for the following reasons (also known as Good Cause Disenrollment reasons1 :
•You are getting care at this time from a provider that is not part of our plan but is a part of another health plan.
•We do not cover a service for moral or religious reasons.
•You are an American Indian or Alaskan Native.
1For the full list of Good Cause Disenrollment reasons, please see Florida Administrative Rule
Questions? Call Member Services at |
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You can also leave our plan for the following reasons, if you have completed our appeal process2:
•You receive poor quality of care, and the Agency for Health Care Administration agrees with you after they have looked at your medical records.
•You cannot get the services you need through our plan, but you can get the services you need through another plan.
•Your services were delayed without a good reason.
If you have any questions about whether you can change plans, call Member Services or the State’s Enrollment Broker at
Removal from Our Plan (Involuntary Disenrollment)
The Agency for Health Care Administration can remove you from our plan (and sometimes the SMMC program entirely) for certain reasons. This is called involuntary disenrollment. These reasons include:
•You lose your Medicaid.
•You move outside of where we operate, or outside the state of Florida.
•You knowingly use your plan ID card incorrectly or let someone else use your plan ID card.
•You fake or forge prescriptions.
•You or your caregivers behave in a way that makes it hard for us to provide you with care.
If the Agency for Health Care Administration removes you from our plan because you broke the law or for your behavior, you cannot come back to the SMMC program.
Section 9: Managing Your Care
If you have a dental condition that requires extra support and coordination, you may have a case manager with us. If you have a medical condition or illness that requires extra support and coordination, you may have a case manager with your Medicaid health plan. Whether you have a dental case manager or a health plan case manager, your case manager can help you get the services you need. Your case manager may work with us to coordinate your dental care with your other health care services. If you have a case manager assigned by your Medicaid health plan, call Member Services to let us know.
2To learn how to ask for an appeal, please turn to page Section 13, Member Satisfaction, on pages 25 through 28.
Questions? Call Member Services at |
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Section 10: Accessing Services
Before you get a service or go to some dental appointments, we have to make sure that you need the service and that it is medically right for you. This is called prior authorization. To do this, we look at your medical history and information from your dentist, doctor, or other health care providers. Then we will decide if that service can help you. We use rules from the Agency for Health Care Administration to make these decisions.
Continuing Your Care
When you first enroll in our plan, you may already be receiving services from a provider(s). We will make sure you keep getting the care your providers give you. You can keep getting your care from that provider for up to 120 days.
Before 120 days, your provider must check with us to keep giving your services to you. If your provider is not in our plan, we will help you find a new provider that is in our plan, schedule an appointment, and move your health records to the new provider. If you have questions, call Member Services.
Providers in Our Plan
For the most part, you must use dentists and other dental providers that are in our provider network. Our provider network is the group of dentists and other dental providers that we work with. You can choose from any provider in our provider network. This is called your freedom of choice. If you use a dental provider that is not in our network, you may have to pay for that appointment or service.
You will find a list of providers that are in our network in our provider directory. If you do not have a provider directory, call
Providers Not in Our Plan
There are sometimes when you can get from providers who are not in our plan. If you need a service and we cannot find a provider in our plan for these services, we will help you find another provider that is not in our plan. Remember to check with us first before you use a provider that is not in our provider network. If you have questions, call Member Services.
When We Pay for Your Services
We will cover most of your dental services, but some services may be covered by your medical plan. The table below will help you to decide which plan pays for a service.
Questions? Call Member Services at |
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Type of Dental Service(s): |
Dental Plan Covers: |
Medical Plan Covers: |
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Dental Services |
Covered when you see your |
Covered when you see your |
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dentist or dental hygienist |
doctor or nurse |
Scheduled dental services in |
Covered for dental services |
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a hospital or surgery center |
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hospitals, and surgery centers |
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What Do I Have To Pay For?
You may have to pay for appointments or dental services that are not covered. A covered service is a service that we have to provide in the Medicaid program. All of the services listed in this handbook are covered services. Remember, just because a service is covered, does not mean that you will need it. You may have to pay for services if we did not approve it first.
If you get a bill from a provider, call Member Services. Do not pay the bill until you have spoken to us. We will help you.
Services for Children3
We must provide all medically necessary dental services for our members who are ages 0 – 20 years old. This is the law. This is true even if we do not cover a service or the service has a limit. As long as your child’s dental services are medically necessary, dental services have:
•No dollar limits; or
•No time limits, like hourly or daily limits
Your dental provider may need to ask us for approval before giving your child the service. Call Member Services if you want to know how to ask for these services.
3Also known as “Early and Periodic Screening, Diagnosis, and Treatment” or “EPSDT” requirements.
Questions? Call Member Services at |
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Moral or Religious Objections
If we do not cover a service because of a religious or moral reason, we will tell you that the service is not covered. In these cases, you must call the State’s Enrollment Broker at
Section 11: Helpful Information About Your Benefits
Choosing a Primary Dental Provider (PDP)
One of the first things you will need to do when you enroll in our plan is choose a primary dental provider (PDP). This is a general dentist or pediatric dentist. You will see your PDP for regular dental visits, or when you have a dental problem. Your PDP will also help you get care from other providers or specialists. This is called a referral. You can choose your PDP by calling Member Services.
You can choose a different PDP for each family member or you can choose one PDP for the entire family. If you do not choose a PDP, we will assign a PDP for you and your family.
You can change your PDP at any time. To change your PDP, call Member Services.
Choosing a PDP for Your Child
It is important that you select a PDP for your child to make sure they get their
You can take your child to a pediatric dentist or dentist.
You do not need a referral for dental services to prevent dental problems and keep your mouth healthy. Dental services to prevent dental problems and keep your mouth healthy can be a review of your mouth by a dental provider (screenings or exams), teeth cleanings, and thin plastic coatings painted onto the grooves of your
Specialist Care and Referrals
Sometimes, you may need to see a provider other than your PDP for dental problems like special conditions, injuries, or illnesses. Talk to your PDP first. Your PDP will refer you to a specialist. A specialist is a provider that focuses on one type of health service.
4For more information about the screenings and assessments that are recommended for children, please refer to the “Recommendations for Preventative Pediatric Health Care – Periodicity Schedule” at www.aap.org.
Questions? Call Member Services at |
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If you have a case manager, make sure you tell your case manager about your referrals. The case manager will work with the specialist to get you care.
Second Opinions
You have the right to get a second opinion about your care. This means talking to a different provider to see what they have to say about your care. The second provider will give you their point of view. This may help you decide if certain services or treatments are best for you. There is no cost to you to get a second opinion.
Your PDP, case manager or Member Services can help find a provider to give you a second opinion. You can pick any of our providers. If you are unable to find a provider with us, we will help you find a provider that is not in our provider network. If you need to see a provider that is not in our provider network for the second opinion, we must approve it before you see them.
Hospital Care
If you need to go to the hospital for an appointment, surgery or overnight stay, your PDP will help to request approval for dental services. We must approve a dental provider’s services in the hospital before you go, except for emergencies. We will not pay for a dental provider’s services in a hospital unless we approve them ahead of time or it is an emergency.
If you have a case manager, they will work with you and your dental provider to get services in place for after you leave the hospital.
Emergency Care
You have a dental emergency when you need immediate attention to stop bleeding, relieve severe pain, or save a tooth. Some examples are:
•Abscess
•Bleeding that will not stop
•Infection
Emergency services are what you get when you are very ill or injured. These services try to keep you alive or to keep you from getting worse. They are usually delivered in an emergency room.
If your condition is severe, call 911 or go to the closest emergency facility right away. You can go to any hospital or emergency facility. If you are not sure if it is an emergency, call your PDP. Your PDP will tell you what to do.
We pay for emergency services that are provided by a dental provider, even if they are not part of our plan or in our service area. Medicaid or your Medicaid health plan pays the cost of the hospital or emergency facility and for any care not provided by a dental
Questions? Call Member Services at |
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provider. You also do not need to get approval ahead of time to get emergency care or for the services that you receive in an emergency room to treat your condition.
If you have an emergency when you are away from home, get the medical care you need. Be sure to call Member Services when you are able and let us know.
Urgent Care
Urgent Care is not Emergency Care. Urgent Care is needed when you have an injury or illness that must be treated within 48 hours. Your health or life are not usually in danger, but you cannot wait to see your PDP or it is after your PDP’s office has closed. Be sure to ask us before you use an Urgent Care center, or you may have to pay for those services.
If you need Urgent Care after office hours and you cannot reach your PDP, call our 24 hour on call service at
You may also find the closest Urgent Care center to you by looking online or in the yellow pages.
Filling Prescriptions
We do not pay for prescription drugs. If your PDP orders a drug for you, we can help you get that drug through Medicaid or your Medicaid health plan. You can call Member Services if you need help.
Enrollee Reward Programs
We offer dental programs to help keep you healthy and to help you live a healthier life. We call these healthy behavior programs. You can earn rewards while participating in these programs. Our plan offers the following dental programs:
First Tooth/First Birthday: Children who receive a
Pregnant Women: Women who receive a dental
Fluoride Alternative Products: Children can receive Xylitol products, like tooth get, after completing certain service with their primary dentist.
School Based Services: Children can receive certain dental services in school, like a cleaning. Children may receive a coloring book, crayons, stickers or a back pack with a dental kit.
Questions? Call Member Services at |
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Please remember that rewards 180 days, you may not receive these programs, please call us
cannot be transferred. If you leave our plan for more than your reward. If you have questions or want to join any of
Quality Enhancement Programs
We want you to get quality health care. We offer additional programs that help make the care you receive better. The programs are:
You also have a right to tell us about changes you think we should make.
To get more information about our quality enhancement program or to give us your ideas, call Member Services.
Section 12: Your Plan Benefits: Dental Services
The table below lists the dental services that we cover. Remember, you may need a referral from your doctor, dentist, or approval from us before you go to an appointment or use a service. Services must be medically necessary in order for us to pay for them5. You may have a $3.00 copayment per day for a
If there are changes in covered services or other changes that will affect you, we will notify you in writing at least 30 days before the effective date of the change.
Children don’t have to ask us to
Adults do need to ask up to
If you have questions about any of the covered medical services, please call Member Services at
5You can find the definition for Medical Necessity at http://ahca.myflorida.com/medicaid/review/General/59G_1010_Definitions.pdf
Questions? Call Member Services at |
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• |
1 series of |
|
ray every 3 |
|
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||
|
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|
|
|
Bitewings every |
|
years |
|
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||
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|
|
181 days |
• |
1 view of the |
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|
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||
|
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|
|
• |
1 view of the |
|
whole mouth |
|
|
|
||
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|
|
whole mouth |
|
(panoramic) |
|
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||
|
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|
(panoramic) |
|
every 3 years |
|
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||
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|
|
every 3 years |
• |
Other single x- |
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|
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||
|
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|
|
• |
Other |
|
rays if needed |
|
|
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||
|
|
|
|
|
|
needed |
|
|
|
|
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|
|
Teeth |
|
Basic cleanings |
|
Teeth Cleanings are |
|
Teeth Cleanings |
|
|
You don’t have |
|||
|
Cleanings |
|
that may include |
|
Covered: |
|
are Not covered |
|
|
to ask us for |
|||
|
|
|
brushing, |
|
• 1 time every 181 |
|
|
|
|
|
approval |
||
|
|
|
flossing, |
|
|
days |
|
|
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|
|
scrubbing, and |
|
|
|
|
|
|
|
|
|
|
|
|
|
polishing teeth |
|
|
|
|
|
|
|
|
|
|
|
Questions? Call Member Services at |
19 |
|||||||||||
Fluoride |
A medicine put |
Fluoride is covered: |
Fluoride is Not |
You don’t have |
||
|
on teeth to make |
• |
1 Fluoride every |
Covered |
to ask us for |
|
|
them stronger |
|
90 days for ages |
|
approval |
|
|
|
|
|
|
|
|
|
|
• |
2 Fluorides every |
|
|
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|
|
1 year for ages 6 |
|
|
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|
|
and over |
|
|
|
Sealants |
Thin, plastic |
Sealants are |
Sealants are Not |
You don’t have |
||
|
coatings painted |
covered: |
Covered |
to ask us for |
||
|
into the grooves |
• 1 time every 3 |
|
approval |
||
|
of adult chewing |
|
years for each |
|
|
|
|
surface teeth to |
|
(back) molar |
|
|
|
|
help prevent |
|
tooth |
|
|
|
|
cavities |
• |
Certain terms |
|
|
|
|
|
|
apply |
|
|
|
|
|
|
|
|
|
|
Oral Health |
Education on |
Oral health |
Oral health |
You don’t have |
||
Instructions |
how to brush, |
instructions are |
instructions are |
to ask us for |
||
|
floss, and keep |
covered |
Not Covered |
approval |
||
|
your teeth |
|
|
|
|
|
|
healthy |
|
|
|
|
|
Space |
A way to keep |
Space Maintainers |
Space maintainers |
You don’t have |
||
Maintainers |
space in the |
are Covered: |
are Not Covered |
to ask us for |
||
|
mouth when a |
• |
if medically |
|
approval |
|
|
tooth is taken out |
|
necessary |
|
|
|
|
or missing |
• |
Certain terms |
|
|
|
|
|
|
apply |
|
|
|
Fillings and |
A dental service |
Fillings and Crowns |
Fillings and |
You don’t have |
||
Crowns |
to fix or repair |
are Covered: |
Crowns are Not |
to ask us for |
||
|
teeth |
• |
if medically |
Covered |
approval |
|
|
|
|
necessary |
|
|
|
|
|
• |
Certain terms |
|
|
|
|
|
|
apply |
|
|
|
Prefabricated |
A dental service |
Prefabricated |
Prefabricated |
You don’t have |
||
Stainless Steel |
to fix or repair |
Stainless Steel |
Stainless Steel |
to ask us for |
||
Crowns |
baby (primary) |
Crowns Covered: |
Crowns are Not |
approval. |
||
|
teeth and adult |
• |
if medically |
Covered |
|
|
|
(permanent) |
|
necessary |
|
|
|
|
teeth |
• For ages 6 and |
|
|
|
|
|
|
|
over |
|
|
|
Root Canals |
A dental service |
Root Canals are |
Root Canals are |
You don’t have |
||
|
to fix the inside |
Covered: |
Not Covered |
to ask us for |
||
|
part of a tooth |
• |
If medically |
|
approval. |
|
|
(nerve) |
|
necessary |
|
|
|
|
|
• |
Certain terms |
|
|
|
|
|
|
apply |
|
|
|
Questions? Call Member Services at |
20 |
|||||
Periodontics |
Deep cleanings |
|
Periodontics are |
|
Periodontics are |
You don’t have |
|||
|
that may involve |
|
Covered: |
|
Not Covered |
to ask us for |
|||
|
both your teeth |
|
|
• |
if medically |
|
|
|
approval |
|
and gums |
|
|
|
necessary |
|
|
|
|
|
|
|
|
• |
Certain terms |
|
|
|
|
|
|
|
|
|
apply |
|
|
|
|
Prosthodontics |
Dentures or other |
|
Dentures are |
|
Dentures are |
Adults have to |
|||
|
types of objects |
|
covered: |
|
covered: |
ask us for |
|||
|
to replace teeth |
|
• 1 upper full set or |
|
• 1 upper full set |
approval |
|||
|
|
|
|
partial denture, |
|
|
or partial |
|
|
|
|
|
• 1 lower full set or |
|
|
denture, |
|
||
|
|
|
|
partial denture, or |
|
• 1 lower full set |
|
||
|
|
|
• 1 set of full |
|
|
or partial |
|
||
|
|
|
|
dentures |
|
|
denture, or |
|
|
|
|
|
• |
1 flipper |
|
• 1 set of full |
|
||
|
|
|
|
(immediate |
|
• |
dentures |
|
|
|
|
|
|
denture) to |
|
1 flipper |
|
||
|
|
|
|
replace upper |
|
|
(immediate |
|
|
|
|
|
• |
front teeth |
|
|
denture) to |
|
|
|
|
|
1 improvement |
|
|
replace upper |
|
||
|
|
|
|
for denture fit and |
|
• |
front teeth |
|
|
|
|
|
|
comfort (reline) |
|
1 improvement |
|
||
|
|
|
|
for every 366 |
|
|
for denture fit |
|
|
|
|
|
|
days per full |
|
|
and comfort |
|
|
|
|
|
|
denture or partial |
|
|
(reline) for |
|
|
|
|
|
|
denture |
|
|
every 366 days |
|
|
|
|
|
|
|
|
|
|
per full denture |
|
|
|
|
|
|
|
|
|
or partial |
|
|
|
|
|
|
|
|
|
denture |
|
Orthodontics |
Braces or other |
|
Braces are only |
|
Braces are Not |
Ask us for |
|||
|
ways to correct |
|
covered: |
|
Covered |
approval |
|||
|
teeth location |
|
• |
If medically |
|
|
|
before you go |
|
|
|
|
|
necessary |
|
|
|
to an |
|
|
|
|
• |
Certain terms |
|
|
|
appointment |
|
|
|
|
|
apply |
|
|
|
for these |
|
|
|
|
|
|
|
|
|
|
services |
Extractions |
Tooth removal |
|
Extractions are |
|
Extractions are |
Adults ask us |
|||
|
|
|
Covered: |
|
Covered: |
for approval |
|||
|
|
|
• |
If medically |
|
• |
If medically |
before you go |
|
|
|
|
|
necessary |
|
|
necessary |
to an |
|
|
|
|
• |
Certain terms |
|
• |
Certain terms |
appointment |
|
|
|
|
|
apply |
|
|
apply |
for these |
|
|
|
|
|
|
|
|
|
|
services |
Questions? Call Member Services at |
21 |
Other Oral |
Correct problem |
Other Oral Surgery |
Other Oral Surgery |
Adults ask us |
||
Surgery |
in the mouth |
Services are |
Services are |
for approval |
||
Services |
|
Covered: |
Covered: |
before you go |
||
|
|
• |
If medically |
• |
If medically |
to an |
|
|
|
necessary |
|
necessary |
appointment |
|
|
• |
Certain terms |
• |
Certain terms |
for these |
|
|
|
apply |
|
apply |
services |
Sedation |
A way to provide |
Sedation is Covered: |
Sedation is |
Adults ask us |
||
|
dental services |
• |
If medically |
Covered: |
for approval |
|
|
where a patient is |
|
necessary |
• |
3 occurrences |
before you go |
|
asleep or partially |
• |
Certain terms |
|
every 366 days |
to an |
|
asleep |
|
apply |
• |
Certain terms |
appointment |
|
|
|
|
|
apply |
for these |
|
|
|
|
|
|
services |
Ambulatory |
Dental services |
Hospital Setting |
Hospital Setting |
Adults ask us |
||
Surgical |
that cannot be |
Services are |
Services are |
for approval |
||
Center or |
done in a dentist |
Covered: |
Covered: |
before you go |
||
office. |
• |
If medically |
• |
Only if |
to an |
|
Dental |
These are |
|
necessary for any |
|
medically |
appointment |
Services |
services that |
|
dental services |
|
necessary for |
for these |
|
need to be |
|
needed |
|
extractions |
services |
|
provided with |
• |
Certain terms |
• |
Certain terms |
|
|
different |
|
apply |
|
apply |
|
|
equipment and |
|
|
|
|
|
|
possibly different |
|
|
|
|
|
|
providers |
|
|
|
|
|
Questions? Call Member Services at |
22 |
Your Plan Benefits: Expanded Benefits
Expanded benefits are extra goods or services we provide to you, free of charge. Call Member Services to ask about getting expanded benefits. These extra services are provided to adults that are 21 years or older. For pregnant women that are 21 years and older, more services may be available to help with a healthy pregnancy.
Service |
Description |
|
Coverage/ Limitations |
Prior |
|
||
|
|
|
Adults |
|
Pregnant |
Authorization |
|
|
|
|
(ages 21+) |
Adults (ages |
|
|
|
|
|
|
|
|
21+) |
|
|
|
|
|
|
|
|
|
|
Dental |
A review of |
Dental exams |
Dental exams |
You don’t have |
|||
exams |
your tooth, |
are Covered: |
are Covered: |
to ask us for |
|
||
|
teeth, or |
• |
A |
• |
A |
approval |
|
|
mouth by a |
|
exam is |
|
exam is |
|
|
|
dentist |
|
covered 2 |
|
covered 2 |
|
|
|
|
|
times every |
|
times every |
|
|
|
|
|
1 year |
|
1 year |
|
|
Dental |
A review of |
Dental |
Dental |
You don’t have |
|||
screenings |
your mouth by |
Screenings are |
Screenings are |
to ask us for |
|
||
|
a dental |
covered: |
covered: |
approval |
|
||
|
hygienist |
• |
2 times |
• |
2 times |
|
|
|
|
|
every 1 year |
|
every 1 year |
|
|
Dental |
Internal |
Dental |
Dental |
You don’t have |
|||
|
pictures of |
are Covered: |
are Covered: |
to ask us for |
|
||
|
teeth with |
• |
1 series of |
• |
1 series of |
approval |
|
|
different views |
|
Bitewings |
|
Bitewings |
|
|
|
|
|
every year |
|
every year |
|
|
|
|
• |
Other single |
• |
Other single |
|
|
|
|
|
|
|
|
||
|
|
|
needed |
|
needed |
|
|
|
|
|
|
|
|||
Teeth |
Basic |
Teeth |
Teeth |
You don’t have |
|||
Cleanings |
cleanings that |
Cleanings are |
Cleanings are |
to ask us for |
|
||
|
may include |
Covered: |
Covered: |
approval |
|
||
|
brushing, |
• |
2 times |
• |
2 times |
|
|
|
flossing, |
|
every 1 year |
|
every 1 year |
|
|
|
scrubbing, and |
|
|
|
|
|
|
|
polishing teeth |
|
|
|
|
|
|
Fluoride |
A medicine put |
Fluoride is |
Fluoride is |
You don’t have |
|||
|
on teeth to |
Covered: |
Covered: |
to ask us for |
|
||
|
make them |
• |
2 times |
• |
2 times |
approval |
|
|
stronger |
|
every 1 year |
|
every 1 year |
|
|
|
|
|
|
|
|||
Sealants |
Thin, plastic |
Sealants are |
Sealants are |
You don’t have |
|||
|
coatings |
Covered |
Covered |
to ask us for |
|
||
|
painted into |
|
|
|
|
approval |
|
Questions? Call Member Services at |
23 |
||||||
|
the grooves of |
• |
1 time every |
• |
1 time every |
|
|
adult chewing |
|
3 years for |
|
3 years for |
|
|
surface teeth |
|
each (back) |
|
each (back) |
|
|
to help prevent |
|
molar tooth |
|
molar tooth |
|
|
cavities |
• |
Certain |
• |
Certain |
|
|
|
|
terms apply |
|
terms apply |
|
|
|
|
|
|
|
|
Oral Health |
Education on |
Oral health |
Oral health |
You don’t have |
||
Instructions |
how to brush, |
instructions are |
instructions are |
to ask us for |
||
|
floss, and |
Covered: |
Covered: |
approval |
||
|
keep your |
• |
2 times |
• |
2 times |
|
|
teeth healthy |
|
every 1 year |
|
every 1 year |
|
|
|
|
|
|
||
Fillings |
A dental |
Fillings are |
Fillings are |
You don’t have |
||
|
service to fix |
Covered: |
Covered: |
to ask us for |
||
|
or repair teeth |
• |
1 per tooth |
• |
1 per tooth |
approval |
|
|
|
surface |
|
surface |
|
|
|
|
every 3 |
|
every 3 |
|
|
|
|
years |
|
years |
|
|
|
|
|
|
|
|
Periodontics |
Deep |
Deep cleanings |
Deep cleanings |
Adults ask us |
||
|
cleanings that |
are covered: |
are covered: |
for approval |
||
|
may involve |
• |
Full mouth 1 |
• |
Full mouth 1 |
before you go |
|
both your |
|
every 24 |
|
every 24 |
to an |
|
teeth and |
|
months |
|
months |
appointment for |
|
gums |
• |
Certain |
• |
Certain |
these services |
|
|
|
terms apply |
|
terms apply |
|
|
|
|
|
|
||
General |
Dental |
Dental |
Dental |
You don’t have |
||
Services |
consultations |
Consultation is |
Consultation is |
to ask us for |
||
|
to visit a |
Covered: |
Covered: |
approval |
||
|
dentist for an |
• |
1 every year |
• |
1 every year |
|
|
opinion and |
• |
Certain |
• |
Certain |
|
|
dental pain |
|
terms apply |
|
terms apply |
|
|
treatment |
|
|
|
|
|
Questions? Call Member Services at |
24 |
Diabetic |
Dental office |
Diabetic testing |
Diabetic testing |
You don’t have |
|
Testing |
diabetes |
is Covered: |
is Covered: |
to ask us for |
|
|
testing |
• |
1 time every |
1 time every 1 |
approval |
|
|
|
1 year |
year |
|
Dental Office |
A visit to the |
• |
Covered for |
• Covered for |
You don’t have |
Visit for |
dental office to |
|
persons with |
persons with |
to ask us for |
Persons with |
get |
|
intellectual |
intellectual |
approval |
Disabilities |
comfortable |
|
disabilities 1 |
disabilities 1 |
|
|
with the office |
|
time for |
time for |
|
|
and the dentist |
|
every new |
every new |
|
|
|
|
dental office |
dental office |
|
|
|
|
or dentist |
or dentist |
|
|
|
|
before |
before |
|
|
|
|
dental work |
dental work |
|
|
|
|
is done |
is done |
|
Section 13: Member Satisfaction
Complaints, Grievances, and Plan Appeals
We want you to be happy with us and the care you receive from our providers. Let us know right away if at any time you are not happy with anything about us or our provider(s). This includes if you do not agree with a decision we have made.
|
What You Can Do: |
|
What We Will Do: |
|
|
|
|
If you are not happy |
You can: |
|
We will: |
with us or our |
• Call us at any time at |
|
• Try to solve your issue |
providers, you can file |
|
within one business day. |
|
a Complaint |
TTY |
|
|
|
|
|
|
If you are not happy |
You can: |
|
We will: |
with us or our |
• Write us or call us at any |
|
• Review your grievance |
providers, you can file |
time. |
|
and send you a letter |
a Grievance |
• Call us to ask for more |
|
with our decision within |
|
time to solve your |
|
30 days. |
|
grievance if you think |
|
If we need more time to |
|
more time will help. |
|
|
|
LIBERTY Dental Plan |
|
solve your grievance, we |
|
Grievance Department |
|
will: |
|
P.O. Box 15149 |
|
• Send you a letter with |
|
Tampa, FL 33684 |
|
our reason and tell you |
|
|
about your rights if you |
|
|
TTY |
|
disagree. |
Questions? Call Member Services at |
25 |
If you do not agree |
You can: |
|
We will: |
|
with a decision we |
• Write us, or call us and |
|
• Send you a letter within 3 |
|
made about your |
follow up in writing, within |
|
business days to tell |
|
services, you can ask |
60 days of our decision |
|
you we received your |
|
for an Appeal |
about your services. |
|
appeal. |
|
|
• Ask for your services to |
|
• Help you complete any |
|
|
continue within 10 days |
|
forms. |
|
|
of receiving our letter, if |
|
• Review your appeal and |
|
|
needed. Some rules may |
|
send you a letter within |
|
|
apply. |
|
20 days to answer you. |
|
|
LIBERTY Dental Plan |
|
|
|
|
Appeals Department |
|
|
|
|
P.O. Box 15149 |
|
|
|
|
Tampa, FL 33684 |
|
|
|
|
|
|
|
|
|
TTY |
|
|
|
If you think waiting for |
You can: |
|
We will: |
|
30 days will put your |
• Write us or call us within |
|
• Give you an answer |
|
health in danger, you |
60 days of our decision |
|
within 48 hours after we |
|
can ask for an |
about your services. |
|
receive your request. |
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Expedited or “Fast” |
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Fast Plan Appeal
If we deny your request for a fast appeal, we will transfer your appeal into the regular appeal time frame of 20 days. If you disagree with our decision not to give you a fast appeal, you can call us to file a grievance.
Medicaid Fair Hearings (for Medicaid Enrollees)
You may ask for a fair hearing at any time up to 120 days after you get a Notice of Plan Appeal Resolution by calling or writing to:
Agency for Health Care Administration Medicaid Fair Hearing Unit
P.O. Box 60127
Ft. Meyers, FL 33906
If you request a fair hearing in writing, please include the following information:
•Your name
•Your member number
•Your Medicaid ID number
•A phone number where you or your representative can be reached
You may also include the following information, if you have it:
•Why you think the decision should be changed
•Any medical information to support the request
•Who you would like to help with your fair hearing
After getting your fair hearing request, the Agency for Health Care Administration will tell you in writing that they got your fair hearing request. A hearing officer who works for the State will review the decision we made.
If you are a Title XXI MediKids enrollee, you are not allowed to have a Medicaid Fair Hearing.
Review by the State (for MediKids Enrollees)
When you ask for a review, a hearing officer who works for the state reviews the decision made during the plan appeal. You may ask for a review by the state any time up to 30 days after you get the notice. You must finish your appeal process first.
Questions? Call Member Services at |
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You may ask for a review by the state by calling or writing to:
Agency for Health Care Administration
P.O. Box 60127
Ft. Myers, FL 33906
(877)
After getting your request, the Agency for Health Care Administration will tell you in writing that they got your request.
Continuation of Benefits for Medicaid Enrollees
If you are now getting a service that is going to be reduced, suspended or terminated, you have the right to keep getting those services until a final decision is made for your Plan appeal or Medicaid fair hearing. If your services are continued, there will be no change in your services until a final decision is made.
If your services are continued and our decision is not in your favor, we may ask that you pay for the cost of those services. We will not take away your Medicaid benefits. We cannot ask your family or legal representative to pay for the services.
To have your services continue during your appeal or fair hearing, you must file your appeal and ask to continue services within this timeframe, whichever is later:
•10 days after you receive a Notice of Adverse Benefits Determination (NABD), or
•On or before the first day that your services will be reduced, suspended or terminated.
Section 14: Your Enrollee Rights
As a recipient of Medicaid and an enrollee in a plan, you also have certain rights. You have the right to:
•Be treated with courtesy and respect
•Have your dignity and privacy respected at all times
•Receive a quick and useful response to your questions and requests
•Know who is providing medical services and who is responsible for your care
•Know what member services are available, including whether an interpreter is available if you do not speak English
•Know what rules and laws apply to your conduct
•Be given information about your diagnosis, the treatment you need, choices of treatments, risks, and how these treatments will help you
•Say no any treatment, except as otherwise provided by law
•Be given full information about other ways to help pay for your health care
Questions? Call Member Services at |
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•Know if the provider or facility accepts the Medicare assignment rate
•To be told prior to getting a service how much it may cost you
•Get a copy of a bill and have the charges explained to you
•Get medical treatment or special help for people with disabilities, regardless of race, national origin, religion, handicap, or source of payment
•Receive treatment for any health emergency that will get worse if you do not get treatment
•Know if medical treatment is for experimental research and to say yes or no to participating in such research
•Make a complaint when your rights are not respected
•Ask for another doctor when you do not agree with your doctor (second medical opinion)
•Get a copy of your medical record and ask to have information added or corrected in your record, if needed
•Have your medical records kept private and shared only when required by law or with your approval
•Decide how you want medical decisions made if you can’t make them yourself (advanced directive)
•To file a grievance about any matter other than a plan’s decision about your services.
•To appeal a plan’s decision about your services
•Receive services from a provider that is not part of our plan
Section 15: Your Enrollee Responsibilities
As a recipient of Medicaid and an enrollee in a dental plan, you also have certain responsibilities. You have the responsibility to:
•Give accurate information about your health to your plan and providers
•Tell your provider about unexpected changes in your health condition
•Talk to your provider to make sure you understand a course of action and what is expected of you
•Listen to your provider, follow instructions and ask questions
•Keep your appointments or notify your provider if you will not be able to keep an appointment
•Be responsible for your actions if treatment is refused or if you do not follow the health care provider's instructions
•Make sure payment is made for
•Follow health care facility conduct rules and regulations
•Treat health care staff with respect
•Tell us if you have problems with any health care staff
•Use the emergency room only for real emergencies
Questions? Call Member Services at |
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•Notify your case manager if you have a change in information (address, phone number, etc.)
•Have a plan for emergencies and access this plan if necessary for your safety
•Report fraud, abuse and overpayment
Section 16: Other Important Information
Emergency Disaster Plan
Disasters can happen at any time. To protect yourself and your family, it is important to be prepared. There are three steps to preparing for a disaster: 1) Be informed; 2) Make a Plan and 3) Get a Kit. For help with your emergency disaster plan, call Member Services or your case manager. The Florida Division of Emergency Management can also help you with your plan. You can call them at (850)
Fraud/Abuse/Overpayment in the Medicaid Program
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline
You can also report fraud and abuse to us directly by contacting LIBERTY at:
➢Compliance Hotline:
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➢ Mail: LIBERTY Dental Plan Compliance Department
P.O. Box 15149
Tampa, FL 33684
You can be nameless if you want. All information will be private, and the results will only be shared with people who need to know.
Abuse/Neglect/Exploitation of People
You should never be treated badly. It is never okay for someone to hit you or make you feel afraid. You can talk to your PDP or case manager about your feelings.
If you feel that you are being mistreated or neglected, you can call the Abuse Hotline at
You can also call the hotline if you know of someone else that is being mistreated.
Questions? Call Member Services at |
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Domestic Violence is also abuse. Here are some safety tips:
•If you are hurt, call your primary care provider
•If you need emergency care, call 911 or go to the nearest hospital. For more information, see the section called EMERGENCY CARE
•Have a plan to get to a safe place (a friend’s or relative’s home)
•Pack a small bag, give it to a friend to keep for you
If you have questions or need help, please call the National Domestic Violence Hotline toll free at
Getting More Information
You have a right to ask for information. Call Member Services or talk to your case manager about what kinds of information you can receive for free. Some examples are:
•Your enrollee record;
•A description of how we operate;
•Quality performance ratings, including member satisfaction survey results;
LIBERTY wants to make getting to know us easy. Please visit us at www.libertydentalplan.com/FLMedicaid or call Member Services at
You can ask us for information on:
•Member satisfaction scores
•Provider satisfaction scores
•Quality performance scores
•LIBERTY operations
You can also get performance and financial data that is handled by the Florida Agency for Health Care Administration (AHCA) at www.FloridaHealthState.com.
Section 17: Additional Resources
Florida Department of Health Information
The Public Health Dental Program leads the Department of Health's efforts to improve and maintain the oral health of all persons in Florida. You can find the following types of information on their website:
•Community Water Fluoridation
•Oral health related sites
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To find more information on the Public Health Dental Program, please visit: www.flhealth.gov/dental
Questions? Call Member Services at |
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To find information on the quality of oral health in your county, please visit: http://www.flhealthcharts.com/ChartsReports/rdPage.aspx?rdReport=ChartsProfiles.Ora lHealthProfile
MediKids Information
For information on MediKids coverage please visit: http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/program_policy/FLKidCar e/MediKids.shtml
Questions? Call Member Services at |
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Section 18: Forms
You can use this form to file a grievance or appeal with LIBERTY Dental Plan (LIBERTY).You can also use this form to give LIBERTY more information to help review your case. If you are filed an appeal over the telephone, you can complete this form and mail to back to LIBERTY. This is optional. W e will review your case without a written appeal.
MEMBER INFORMATION (PLEASE PRINT)
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AUTHORIZED REPRESENTATIVE INFORMATION, IF APPLICABLE (PLEASE
I am authorizing LIBERTY Dental Plan to allow the following person to act on my
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
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If you need help completing this form, call our Member Services Department at (833)
SUMMARY OF GRIEVANCE OR APPEAL
Please share any information you have about your grievance or appeal. Please give us as many details as you can, if possible please provide the dates, names and any treatment. Please share with us how you would like to see your grievance or appeal resolved. If needed you can attach an additional page.
Member SignatureDate
PLEASE SEND COMPLETED SIGNED FORM TO:
Mail to
LIBERTY Dental
Plan of Florida
Grievances and
Appeals
Department
P.O. Box 15149
Tampa, FL 33684
•Fax to LIBERTY’s Grievances and Appeals Department fax at
(833)
•Telephone by calling LIBERTY’s Member Services Department at (833)
•Electronically by using the website online grievance filing process by visiting www.libertydentalplan.com/FLMedicaid.
•Emailing us at: FLGandA@libertydentalplan.com
You may request a copy of your records associated with your active grievance
or appeal in writing to LIBERTY at the address listed above.
Questions? Call Member Services at |
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THE AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA)
FAIR HEARING REQUEST
MAIL TO: Agency for Health Care Administration |
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LIBERTY Dental Plan
Authorization Form for Release of Records and Information
A. Identification
This document authorizes the use and or disclosure of confidential protected health information about the following person:
Member’s Name:
Address:
Date of Birth:
Phone:
Member’s ID:
Please provide the names of the individuals, such as your Spouse, Children or other Relative, that you are authorizing to have access to your information.
Name:Signature:
B. Directions for Release
This authorization applies in accordance with my directions that I authorize the dental office below to release my entire dental record and/or use protected health information pertaining to the member(s) listed in Section A to LIBERTY Dental Plan.
Dental Office Name:
Address:
Phone:
C.Authorization and Signature: I authorize the release of my confidential protected health information, as described in my directions in Section B. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my direction.
I, _____________________, have read the contents of the Authorization , and I
confirm that the contents are consistent with my directions. I understand that by signing this form, I am authorizing the use and /disclosure of my confidential health information. This Release From expires fifteen (15) calendar days from signature date.
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Advance Directive Form
DESIGNATION OF HEALTH CARE SURROGATE
I, ____________________________________, designate as my health care surrogate
under S.765.202, Florida Statues:
Name:
Address:
Phone:
If my health care surrogate is not willing, able, or reasonably available to perform his or her duties, I designate as my alternate health care surrogate:
Name:
Address:
Phone:
INSTRUCTIONS FOR HEALTH CARE
I authorize my health care surrogate to: (Initials required in blank spaces below)
Receive any of my health information, whether oral or recorded in any form or medium that:
1.Is created or received by a health care provider, health care facility, health plan, public heath employer, life insurer, school or university or health care clearinghouse; and
2.Relates to my past, present or future physical or mental health or condition;
the provider of health care to me; or the past, present or future payment for the provisions of health care to me.
I further authorize my health care surrogate to:
A.Make all health care decision for me, which means he or she has the authority to:
1.Provide informed consent, refusal of consent or withdraw of consent to any and all of my health care, including
2.Apply on my behalf for private, public, government or veteran’s benefits to defray the cost of health care.
3.Access my health information reasonably necessary for the health care
surrogate to make decisions involving my health and to apply for benefits for me.
4.Decide to make an anatomical gift pursuant to part V, chapter 765, Florida Statues.
Questions? Call Member Services at |
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Advance Directive Form
Specific instructions and restrictions for my health care surrogate:
While I have decision making capacity, my wishes are controlling, and my physician and health care providers must clearly communicate to me the treatment plan or any change to the treatment plan prior to its implementation. To the extent that I am capable of understanding, my health care surrogate shall keep me reasonably informed of all decisions that he or she has made on my behalf and matters concerning me.
This health care surrogate designation is not affected by my subsequent incapacity except as provided in Chapter 765, Florida Statutes. Pursuant to section 765.104, Florida Statutes, I understand that I may, at any time while I retain my capacity, revoke or amend this designation by:
1.Signing a written and dated instrument which expresses my intent to amend or revoke this designation;
2.Physically destroying this designation through my own action or by that of another person in my presence and under my direction;
3.Verbally expressing my intention to amend or revoke this designation; or
4.Signing a new designation that is materially different from this designation.
My health care surrogate’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I initial either or both of the following boxes:
If I initial this box [ ] my health care surrogate’s authority to receive my health information takes effect immediately.
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Advance Directive Form |
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