HOME   MEDICAL INSURANCE CLAIM FORMS  PRINT AND FAX ORDER FORM

FAX # 1-985-809-5788

All orders will be shipped by UPS Standard Ground Delivery unless other shipping arrangements are required.  Prices quoted do not include freight or any applicable sales tax.

YOU MAY ALSO ORDER BY PHONE TOLL FREE AT: 1-877-840-1500
Our Office Hours are 8-5 Mon.-Fri. CST

*If you have ordered from us before, just fill in
Company Name, Your Name and Products Ordered.

CONTACT INFORMATION

*Company Name_______________________   *Your Name______________________

Phone/Ext. _________________   Fax _________________   E-Mail _______________

CREDIT CARD BILLING INFORMATION

Name as Appears on Card (required)_________________________

Address as Appears on Credit Card

Street Address (required) _______________________________ City_______________  State_____________  Zip Code (required)__________

CHOOSE A CREDIT CARD AND ENTER CARD INFORMATION BELOW OR FAX THIS ORDER FORM AND CALL US TOLL FREE 1-877-840-1500 TO GIVE CARD NUMBER

Credit Card Number_______________________    Expiration Date__________ Security Code as appears on Back of Credit Card_________

*PRODUCTS ORDERED

                                    Form Name             # of Cartons Ordered

HCFA 1500 Continuous-1 Part-bar coded ______
HCFA 1500 Continuous-1 Part-non bar coded ______
HCFA 1500 Continuous-2 Part-bar coded ______
HCFA 1500 Continuous-2 Part-non bar coded ______
HCFA 1500 Laser-bar coded ______
HCFA 1500 Laser-non bar coded ______
HCFA 1500 Snapout Version ______
UB 92 Continuous-1 Part ______
UB 92 Continuous-2 Part ______
UB 92 Continuous-3 Part ______
UB 92 Continuous-4 Part ______
UB 92 Laser ______
ADA 2000 Dental Claim Form Continuous - 1 Part ______
ADA 2000 Dental Claim Form Continuous - 2 Part ______
ADA 2000 Dental Claim Form Laser ______
ADA 2002/2004 Dental Claim Form Continuous - 1 Part ______
ADA 2002/2004 Dental Claim Form Continuous - 2 Part ______
ADA 2002/2004 Dental Claim Form Laser ______
ADA 94 Dental Claim Form Continuous - 1 Part ______
ADA 94 Dental Claim Form Continuous - 2 Part ______
ADA 94 Dental Claim Form Laser ______
Claim Form Envelopes - #10.5 Right-Window ______
Claim Form Envelopes - #9 x 12.5 Right Window ______
Claim Form Envelopes - #9 x 12.5 Left Window ______
HCFA 485 Claim Form ______
HCFA 486 Claim Form ______
HCFA 487 Claim Form ______

Thank-you for your order!
DFL Enterprises,  124 Pine Oak Dr.,  Covington, LA 70433
Phone:1-877-840-1500