More Information For Yourself Or A Loved One

Please complete the form below to obtain more information for yourself or a loved one regarding addiction treatment at Red Oak Recovery^®. If you need immediate assistance, please call us at 866.457.7590.

Your Contact Information
Your Name*
First Last
Return Callback Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A Loved One
How Did You Hear About Us?
Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
Date Format: MM slash DD slash YYYY
Your Date Of Birth*
Date Format: MM slash DD slash YYYY
Additional Information
Insurance Information
Would you like us to verify your or a loved ones insurance benefits?*
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Policy Holders Name*
First Last
Policy Holders Date Of Birth*
Date Format: MM slash DD slash YYYY
Policy Holders Address**
Street Address Address Line 2 City State ZIP Code
Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
Subscriber relationship to client*
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Your Contact Information

Loved Ones Information

Your Information

Insurance Information

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