CREDIT CARD AUTHORIZATION

Credit Card Authorization Form

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