Name: PACE Recovery Center
Telephone: 800-526-1851
Price range: -

PACE Recovery Center Financial Form

PACE Credit Card Authorization Form

If paying for our California addiction treatment program by check or wire transfer, please call 800-526-1851.

To submit your credit card information online, please fill out the secure form below.

"*" indicates required fields

Type of Card:*

Personal Card

Corporate Card

Client Name:*

Daytime Telephone:*

Email Address:*

Fax Number:

Treatment:*

Amount*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cardholder Name:*

Credit Card*

Card Details

Cardholder Name

Today's Date:

All fees are non-negotiable and due and payable at time of admission.
By signing this contract as the responsible party for treatment fees. I further understand that all fees paid are non-refundable regardless of length of stay.
Deposits and payments are non-refundable & non-transferable.
No verbal agreement will supersede this contract.
I hereby agree to hold PACE Recovery Center, LLC harmless for any and all future claims resulting from this contract.

I have read and agreed to the above Terms and Conditions.

I have contacted my credit card provider and placed approval on file for the above submitted PACE program cost.

Name

This field is for validation purposes and should be left unchanged.