Checkout - LIBERTY Dental Plan

CA50 HMO Dental Plan Details (Edit)

Plan Option

Total Amount

Are you in pain and need to see the dentist within 24 hours?

Yes No

Please note that urgent activations can be processed during normal business hours (Mon – Fri 8am-5pm PT) within 3-4 hours. For assistance, please contact 888.273.2719.

Before processing your transaction, you must confirm with the network dentist of your choice that they can accept you as a new patient right away upon activation.

Have you confirmed that your dentist can accept you as a new patient right away upon activation?

Yes No

Your transaction cannot be processed until you have confirmed with your dentist that they can see you right away upon activation.

Were you assisted by an agent or broker?

Yes No

Agent / Broker ID

Agent / Broker Name

Additional Comments

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Plan Options:

Member: One adult with no dependents.
Member +1: One primary adult and one dependent.
Member +2 or more: One primary adult and two or more dependents.

Eligible dependents include:

Your spouse or domestic partner
Unmarried dependent children who are up to the age of 26
Disabled children (over the age of 26) dependent upon you for support and are not able to support themselves due to physical or mental handicap
Adopted or step children meeting the above requirements

Select a Dentist(Edit)

If your selected dentist accepts you as a new patient upon activation of the CA50 HMO Plan, you will be eligible to receive care right away.

Auto-assign my dentist based on my home address

I want to select a dentist

Distance (Miles)

Zip

Show Advanced Search Criteria

Office Number

Office Name

Dentist First Name

Dentist Last Name

Please select dentist.

Enter the valid First Name

Print Dentists

Availability of Language Assistance Services

LIBERTY makes certain language assistance services available to you at no cost. If English is not your preferred language and you need help communicating in your preferred language, you may call 888-703-6999 to ask what language services are available to you.

Enrollees with Disabilities

As a LIBERTY enrollee (including enrollees with disabilities), you have full and equal access to covered services as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.

Directory Information

Did you find information that you think may need to be updated in our provider directories? Click here to let us know so we can fix it. You may also notify LIBERTY about provider directory updates by calling 888-703-6999.

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Primary Member Information(Edit)

First Name

Last Name

Please enter first name.

Please enter last name.

Confirm Email

We guarantee 100% privacy. Your information will never be shared.

Please enter email.

Please confirm email.

Phone #

Please enter phone.

Gender

Date Of Birth (MM/DD/YYYY)

Please select gender.

Please enter date of birth.

Home Address

Please enter home address.

City

State

Zip

Please enter city.

Please enter state.

Please enter zip code.

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Dependent Information(Edit)

First Name

Last Name

Please enter first name.

Please enter last name. Please enter valid last name.

Relationship to Primary Member

Date Of Birth

Gender

Please select relationship.

Please enter date of birth.

Please select gender.

Is your child disabled?
Yes No

Please select if child is disabled. Please select if child is disabled.

Please fax us at (949) 270-0119 and include any of the supporting documents from any of the sources below for the proof of your dependent’s disability. If any questions, please contact 888-273-2719

Any proof that meets the IRS criteria/Award letter
Documentation accepted by your medical insurance carrier
A statement from his or her physician or the court system.

Unmarried dependent children can only be up to the age of 26.

First Name

Last Name

Please enter first name.

Please enter last name.

Relationship to Primary Member

Date Of Birth

Gender

Please select relationship.

Please enter date of birth.

Please select gender.

Is your child disabled?
Yes No

Please select if child is disabled. Please select if child is disabled.

Please fax us at (949) 270-0119 and include any of the supporting documents from any of the sources below for the proof of your dependent’s disability. If any questions, please contact 888-273-2719

Any proof that meets the IRS criteria/Award letter
Documentation accepted by your medical insurance carrier
A statement from his or her physician or the court system.

Unmarried dependent children can only be up to the age of 26.

First Name

Last Name

Please enter first name.

Please enter last name.

Relationship to Primary Member

Date Of Birth

Gender

Please select relationship.

Please enter date of birth.

Please select gender.

Is your child disabled?
Yes No

Please select if child is disabled. Please select if child is disabled.

Please fax us at (949) 270-0119 and include any of the supporting documents from any of the sources below for the proof of your dependent’s disability. If any questions, please contact 888-273-2719

Any proof that meets the IRS criteria/Award letter
Documentation accepted by your medical insurance carrier
A statement from his or her physician or the court system.

Unmarried dependent children can only be up to the age of 26.

First Name

Last Name

Please enter first name.

Please enter last name.

Relationship to Primary Member

Date Of Birth

Gender

Please select relationship.

Please enter date of birth.

Please select gender.

Is your child disabled?
Yes No

Please select if child is disabled. Please select if child is disabled.

Please fax us at (949) 270-0119 and include any of the supporting documents from any of the sources below for the proof of your dependent’s disability. If any questions, please contact 888-273-2719

Any proof that meets the IRS criteria/Award letter
Documentation accepted by your medical insurance carrier
A statement from his or her physician or the court system.

Unmarried dependent children can only be up to the age of 26.

First Name

Last Name

Please enter first name.

Please enter last name.

Relationship to Primary Member

Date Of Birth

Gender

Please select relationship.

Please enter date of birth.

Please select gender.

Is your child disabled?
Yes No

Please select if child is disabled. Please select if child is disabled.

Please fax us at (949) 270-0119 and include any of the supporting documents from any of the sources below for the proof of your dependent’s disability. If any questions, please contact 888-273-2719

Any proof that meets the IRS criteria/Award letter
Documentation accepted by your medical insurance carrier
A statement from his or her physician or the court system.

Unmarried dependent children can only be up to the age of 26.

First Name

Last Name

Please enter first name.

Please enter last name.

Relationship to Primary Member

Date Of Birth

Gender

Please select relationship.

Please enter date of birth.

Please select gender.

Is your child disabled?
Yes No

Please select if child is disabled.
Please select if child is disabled.

Please fax us at (949) 270-0119 and include any of the supporting documents from any of the sources below for the proof of your dependent’s disability. If any questions, please contact 888-273-2719

Any proof that meets the IRS criteria/Award letter
Documentation accepted by your medical insurance carrier
A statement from his or her physician or the court system.

Unmarried dependent children can only be up to the age of 26.

Add a family member

Remove a family member

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Billing Information (Edit)

Same as Primary Member Information

First Name

Last Name

Please enter first name.

Please enter last name.

Phone #

Please enter email.

Please enter phone.

Home Address

Please enter address.

City

State

Zip

Please enter city.

Please select state.

Please enter zip code.

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Please enter all the required field(s) on the below sections:

CA50 HMO Dental Plan Details.
Primay Member Information.
Dependent Information(if applicable).
Billing Information.