Healthy behavior program enrollment (FL Medicaid)

Florida Medicaid enroll in a Healthy Behaviors Program

Please complete one form for each person in your family who would like to join a Healthy Behaviors Program. If you have questions, please call Liberty, toll free at 833-276-0850. You can speak to a live person Monday through Friday, between 8 am and 7 pm. TDD/TTY users call 877-855-8039.

Enrollee first name

Enrollee last name

Date of birth

Medicaid ID number

Phone number

I agree to opt in to Liberty's text messaging program

Cell phone number

I agree to receive emails from Liberty or their gift card vendor

Address

Delivery/due date (pregnant women)

Person filling out form

Relation to enrollee

Date of your dental checkup or service

By submitting this form, I confirm that I understand that I am joining a Healthy Behaviors Program. I understand that rewards are only issued when eligibility and all the conditions mentioned above are met that is based on dental claims or other sources. I understand that final rewards given are based on supplies available.

Last Date of Update 12/21/2021