pace-admissions

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:





*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

  • 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.