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

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

This form currently only allows for up to two patients/twins. If you have more than twins, please add their name and information in Section 4 below.

* First Name

Middle Name

* Last Name

* Gender

* DOB

Ethnicity

* Facility Treated At

Insurance Company

Insurance Phone Number

MA Number

Patient ID Number

* Primary Language

* Unit - Gillette

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

DOB

* Relationship to Patient

* Type of Email

* Cell Phone

Home Phone

Type of Address

* Country

*County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

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

Opt Out

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

Yes

Opt Out

* 4. Insurance Information

Medical Assistance

Private Insurance

No Insurance

Combination

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

Yes

6. Please enter preauthorization number or reason for denial

Notes regarding this request:

If the family is requesting to have more than 2 guests staying overnight, please enter their names, relationship to patient, & birthdate below.

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

Acceptance

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

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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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