PACE Recovery Center Financial Forms

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

To send payment by :

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

PACE Credit Card Authorization Form

  • (Visa/MC: Last 3 digits located on card back in signature panel, Amex: 4-digit number located on card front right)
  • PACE Recovery Center, LLC. Financial Contract for Cost of Treatment

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

Fill in all required fields (*) of the form below

*Type of Card:
Personal CardCorporate Card

*Cardholder Name:

*Client Name:

*Credit Card Billing Address 1:

Credit Card Billing Address 2:

*City

*State

*Postal Code

*Daytime Telephone:

*Email Address:

Fax Number:

*Treatment:

*Amount

*Card Type

*Card Number:

*Expiration Date:

*CID Number:

(Visa/MC: Last 3 digits located on card back in signature panel, Amex: 4-digit number located on card front right)

*Today’s Date:

* PACE Recovery Center, LLC. Financial Contract for Cost of Treatment

Secure Form

  • 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.

Pay by check – Payment Form

Fill in all required fields (*) of the form below

*Client Name:

*Address 1:

Address 2:

*City

*State

*Postal Code

*Contact Number:

*Email Address:

*Treatment:

*Amount

*Check Number:

*Today’s Date:

* PACE Recovery Center, LLC. Financial Contract for Cost of Treatment

Secure Form

  • 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.

Pay with wire transfer – Payment Form

Fill in all required fields (*) of the form below

*Client Name:

*Address 1:

Address 2:

*City

*State

*Postal Code

*Contact Number:

*Email Address:

*Treatment:

*Amount

*Wire Transfer Confirmation Number:

*Today’s Date:

* PACE Recovery Center, LLC. Financial Contract for Cost of Treatment

Secure Form

  • 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.

Contact Us

  • This field is for validation purposes and should be left unchanged.
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Pace Recovery Center will continue to follow the CDC guidelines regarding COVID-19. Visit CDC.gov, for more information.
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