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*
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Email*
Who is seeking treatment?*
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Loved Ones Information
Your Information
Loved Ones Name*
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Loved Ones Date Of Birth*
Your Date Of Birth*
Additional Information
Insurance Information
Would you like us to verify your or a loved ones insurance benefits?*
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Policy Holders Name*
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Policy Holders Date Of Birth*
Policy Holders Address**
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Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
Subscriber relationship to client*
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