American Board of Psychiatry and Neurology, Inc. ~ www.abpn.com ~ Phone: 847.229.6500 ~ Fax: 847.229.6600 ~ Email: questions@abpn.com
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) ______ CVV _______
Name as shown on Credit Card: ____________________________________________________________________
Billing Address: ________________________________________________________________________________
City, State, Zip: ____________________________________________________________________________
Email Address: _______________________________________
Signature of Credit Card holder: _____________________________________________________
American Board of Psychiatry and Neurology, Inc.
7 Parkway North
Deerfield, IL 60015
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