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DFB TPA Services
PO Box 71027
Madison Heights, MI 48071-0027
Toll-Free: 800.538.6040
Office: 248.336.0400
Fax: 248.588.4188
Email:clientservices@dfbenefits.com

If you like to provide additional information, please fill out the form below.

*Company Name:
*First Name:	*Last Name:
City: State: Zip:	Fax:
Home Phone:Daytime Phone:	*Email:
Comments/Questions/Concerns:
For Employees Requesting Claim Assistance
Employee Name:	Employee Soc Sec No.:
Employee Home Address:	City: State:
InsuranceCompany:	Group Number:
Name of Patient:	Relationship to Employee:
Patient Date of Birth:	Date of Service:
Type of Service:	Charge:
If the patient has Medicare or Medicaid:
Part A Medicare Policy Number:
Part B Medicare Policy Number:
Medicaid Policy Number: