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 : check, click here. Close Pay by check – Payment Form Client Name:*Address 1:*Address 2:City*State*Postal Code*Contact Number:*Email Address:*Treatment:*Bed Deposit30 days60 days90 daysOtherAmount*Check Number:*Today’s Date: 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. * 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. CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. wire transfer, click here. Close Pay with wire transfer – Payment Form Client Name:*Address 1:*Address 2:City*State*Postal Code*Contact Number:*Email Address:*Treatment:*Bed Deposit30 days60 days90 daysOtherAmount*Wire Transfer Confirmation Number:*Today’s Date: 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. * 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. CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. To submit your credit card information online, please fill out the secure form below. PACE Credit Card Authorization Form Type of Card:*Personal CardCorporate CardCardholder Name:*Client Name:*Credit Card Billing Address 1:*Credit Card Billing Address 2:City*State*Postal Code*Daytime Telephone:*Email Address:*Fax Number:Treatment:*Bed Deposit30 days60 days90 daysOtherAmount*Card Type*VisaMaster CardAmerican ExpressCard 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 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. PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. 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:Bed Deposit30 days60 days90 daysOther *Amount *Card TypeVisaMaster CardAmerican Express *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 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:Bed Deposit30 days60 days90 daysOther *Amount *Check Number: *Today’s Date: * 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. 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:Bed Deposit30 days60 days90 daysOther *Amount *Wire Transfer Confirmation Number: *Today’s Date: * 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. 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. Call to speak to an admissions counselor 800-526-1851
