Gillette Guest Stay Request

Overnight Stay Request Form

Ronald McDonald Family Room inside Gillette Children’s Specialty Healthcare



1. Stay Request


2. Patient Information



Insurance Company

Insurance Phone Number

MA Number

Patient ID Number

* Primary Language

* Unit - Gillette



3. Guest Information - 18 or Older





4. Additional Information / Medical Billing / Additional Guests

* 1. Are you or any family members (grandparents, aunts, uncles, siblings) a Veteran or serving in the military?

* 2. Does your family receive any form of public assistance?

* 4. Insurance Information

* 5. Have you called for preauthorization of lodging? (If NO, please call now)

6. Please enter preauthorization number or reason for denial


Notes regarding this request:



Acceptance

Your request will be processed. Do you want to continue?



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