Kapolei Walmart Payment Form This form is for patients to pay Hawaii Vision Associates through Authorize.net Patient's Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY What is this payment for?* Exam Copayment Balance on the Account Invoice #Amount Due* Payment Amount*Billing Address for the cardholder* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cardholder's Phone Number*Cardholder's Email Address* Payment Type*Credit CardDebit CardCredit/Debit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name