Gillette Guest Stay Request

Overnight Stay Request Form

Ronald McDonald Family Room inside Gillette Children’s Specialty Healthcare


1. Stay Request


2. Patient Information


* - 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.
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
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]


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?

Notes regarding this request:



Acceptance

Please select YES and your request will be processed.



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