Billing Code Request

The DPPS billing staff will process your information and email you when your new DPPS code is enabled in our ordering system.

Use DPPS Code “TEMP” if you have a rush order while we process your request. Please reference the requesting contact or billing contact in special instructions when placing your order.

Billing Code Request

Fill out this form to have a DPPS Code created with your associated billing information.

  • Requester Contact Information

    Fill out the contact information of the person filling out this form.
  • Billing Contact

    Enter in the contact information for the person responsible for the Billing Content. This person will receive all invoices and/or billing communication.
  • Billing

    Fill the billing code details below.
  • Three Digits
  • Seven characters (Alphanumeric)
  • Six Digits
  • One Digit
  • This field is for validation purposes and should be left unchanged.