PACE Recovery Center Financial Forms If paying for our California addiction treatment program by check or wire transfer, please call (877) 405-9411. 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: Corporate Card Personal 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 Type:VisaMasterCardAmerican 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.