Credit Card Authorization Form

"*" indicates required fields

Type of Card:*
Billing Address*

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 Rising Roads harmless for any and all future claims resulting from this contract.
Costs of Treatment Contract*
This field is for validation purposes and should be left unchanged.

Talk to Someone Now at 1-866-746-1558

2750 S Harbor Blvd, #G,  Santa Ana, CA 92704