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PACE Recovery Center Financial Forms

If paying for our California addiction treatment program by check or wire transfer, please call (877) 405-9411.
To send payment by check, click here. To send payment by wire transfer, click here.

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

PACE Credit Card Authorization Form

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.

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.

Call to speak to an admissions counselor 877-405-9411

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