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The Dental Insurance Verification Form is a fundamental administrative document used in Philippine dental practices to verify and document patient insurance coverage prior to providing dental services. This form becomes necessary when patients seek to use their dental insurance benefits and must be completed before initial treatment. It includes comprehensive information about the patient's insurance coverage, policy details, and necessary authorizations, while ensuring compliance with Philippine regulations including the National Health Insurance Act, the Philippine Dental Act of 2007, and the Data Privacy Act of 2012. The document serves multiple purposes: verifying insurance coverage, documenting patient information, obtaining necessary authorizations, and establishing a clear understanding of financial responsibilities between all parties involved.

1. Patient Information: Basic demographic information including full name, date of birth, address, contact numbers, and government-issued ID details

2. Primary Insurance Information: Details about the primary dental insurance policy including insurance company name, policy number, group number, and policyholder information

3. Employment Information: Employment details of the policyholder including employer name, address, and contact information

4. Assignment of Benefits: Authorization for direct payment of dental benefits to the dental provider

5. Release of Information: Authorization to release medical/dental information for insurance purposes

6. Patient/Guardian Signature: Signature section confirming the accuracy of provided information and agreement to terms