Gillette Guest Stay Request

Overnight Stay Request Form

Ronald McDonald Family Room inside Gillette Children’s Specialty Healthcare

Welcome to Ronald McDonald Family Room inside Gillette Childrens Specialty Healthcare!

Families must have a referral from their hospital Social Worker. Social Workers are responsible for prescreening the family to ensure they meet requirements prior to making the referral
Please note: Rooms are not guaranteed & are assigned daily based on patient acuity & availability

If you have questions regarding medical preauthorization/reimbursement, please contact Crystal at 612-767-278 or [email protected]

1. Stay Request

Arrival Date - Please select the date you would like to check into Ronald McDonald Fammily Room (this is NOT your hospital arrival date)
Departure Date - Please select the date you believe you may leave
Please note: Rooms are not guaranteed, it is entirely dependent on what is available

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

* Facility Treated At

* - Primary Language

* -Unit - Gillette

* Insurance Info (Lodging Benefits) - If child has a combination of private and medical assistance, please contact medical assistance first for approval. If denied, then call private insurance. Please note “why” for any denials in the notes section.

Medical Assistance

Private Insurance

No Insurance

Combination

Insurance Provider

Insurance Phone Number

Patient ID Number

Group Number

Have you Called for Pre-Authorization of lodging assistance? (If No, please call now)

Pre-authorization number (if applicable)

Lodging Assistance Status

Approved

Denied

Pending

NA - Not Applicable

Insurance Contact Name

Insurance Contact Phone Number

Insurance Contact Email

Insurance Notes - If you or your county/state and/or member services have any questions about preauthorization/billing, please contact RMHC-UM staff member, Crystal Blank at 612-767-2781 or [email protected]

Add Another Patient

3. Guest Information - 18 or Older

Please enter guests that are 18 years old or older.

For siblings and other guests under 18, please add them under "4 Additional Information" below.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Relationship to Patient

Home Phone

* Mobile Phone

* Country

*County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

COVID-19 Information - At this time, the COVID-19 vaccine status does not affect eligibility

* Vaccination Status

# Vaccinations

Vaccination Note

Add Another Guest

4. Additional Information / Medical Billing / Additional Guests

Ronald McDonald House Charities, Upper Midwest provides a temporary home-away-from home for families with seriously-ill children undergoing medical treatment. We are a non-profit 501(c)(3) public charity. It costs Ronald McDonald House Charities, Upper Midwest $165.00 per night to provide housing to each family at our Ronald McDonald House Northland location.

We currently seek to recover $60 per night in situations where families have medical assistance or private insurance to cover housing costs. Preauthorization is required from your insurance provider in order for us to bill.

If you dont have coverage for housing costs, we encourage a voluntary contribution of $25.00 per night to be made if you are able. However, any contribution is appreciated. No eligible family is ever turned away or asked to the leave because they are unable to make a financial contribution towards their stay.

Please call your county/state financial worker or member services to access your lodging/travel benefits and receive a preauthorization prior to checking into the Ronald McDonald House. Click here to find the contact number for your county.

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

Yes

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

Yes

Notes regarding this request:

Please let us know of any additional information that you feel is relevant for us to know. Thank you!

Acceptance

Please select YES and your request will be processed.

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818 Fulton St SE
Minneapolis, MN 55414

612.331.5752

612.331.1255

[email protected]

Our Mission

We, in partnership with our community, provide a comfortable and caring home-away-from-home that supports keeping families together and reduces stress during a child’s serious illness.

Overnight Stay Request Form

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