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DFB TPA Services
3290 West Big Beaver, Suite 503
Troy, MI 48099
Toll-Free: 800.538.6040
Office: 248.336.0400

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


*Company Name:
*First Name:
*Last Name:
City: x xxxxxxState:x Zip:
Home Phone:xxxxDaytime Phone:
For Employees Requesting Claim Assistance
Employee Name:
Employee Soc Sec No.:
Employee Home Address:
City:xxxxxx State:
Group Number:
Name of Patient:
Relationship to Employee:
Patient Date of Birth:
Date of Service:
Type of Service:
If the patient has Medicare or Medicaid:
Part A Medicare Policy Number:
Part B Medicare Policy Number:
Medicaid Policy Number:xx