Fillable Abpn Credit Card Form printable pdf download

Abpn Credit Card Form

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Credit Card Form

The American Board of Psychiatry and Neurology, Inc. accepts payment by American Express, Discover,

MasterCard or Visa credit cards. Please fill in all requested information and return via mail to the address

listed below or fax to 847.229.6600. If you received a billing statement or letter informing you of fees to be

paid, you must include a copy of the letter with your payment, or attach the appropriate billing statement

or order form.

The ABPN accepts no liability for misdirected or inaccurate information.

If you submit this information via facsimile transmission, please include a Disclaimer in your fax

transmission such as the one provided below:

Disclaimer: This facsimile transmission contains information, which is confidential and/or privileged. This

information is intended for use only by the addressee indicated above. If you are not the intended recipient,

please be advised that any disclosure, copying, distribution, or use of the contents of this information is strictly

prohibited, and that any misdirected or improperly received information must be returned to the sender

immediately.

Please do not use this form for MOC Annual Fee payment. Payment of Annual Fees should be made

through your ABPN Physician Folios account.

PLEASE PROVIDE ALL CREDIT CARD INFORMATION

□

American Express

Discover

MasterCard

Visa Credit Card No. ___________________________________

Amount Authorized for payment: $ __________

Expiration Date (mm/yy) ______

Name as shown on Credit Card: ____________________________________________________________________

Billing Address: ________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________

Billing Phone Number:________________________________________

Signature of Credit Card holder: _____________________________________________________

American Board of Psychiatry and Neurology, Inc.

2150 E. Lake Cook Road, Suite 900

Buffalo Grove, IL 60089

American Board of Psychiatry and Neurology, Inc. ~ ~ Phone: 847.229.6500 ~ Fax: 847.229.6600 ~ Email:

Abpn Credit Card Form

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