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© 2009 DFBenefits. All Rights Reserved.


DFBenefits, Inc.
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:
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Fax:
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 *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: