Name: Tompkins & Associates
Address: 1801 N. Mill Street Suite C, Naperville, Illinois, 60563, US

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I hereby acknowledge that I received an explanation of Dr. Tompkins’ Psy.D. & Associates business practices. I hereby authorize my insurance benefits to be paid directly to Denise Tompkins, Psy.D. & Associates and I hereby authorize the release any information acquired in the course of treatment that is necessary to process insurance claims. I understand that I am responsible for all charges not paid by my insurance. I also agree to pay all collection agency fees should I default in payment.
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