Credit Card Authorization Form

Credit Card Authorization Form

Our online payment option is under construction. Please call to pay by credit card 866-746-1558 

"*" indicates required fields

Type of Card:*
Billing Address*
MM slash DD slash YYYY

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.

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