Children's Minneapolis Guest Stay Request

Overnight Stay Request Form

Children's Minnesota - Minneapolis Hospital

1. Stay Request

2. Patient Information

Insurance Company

Insurance Phone Number

MA Number

Patient ID Number

* Primary Language

* Unit - HIH

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?

* 3. Expected Stay Length

* 4. Insurance Information

4b. County Social Worker

* 4c. County Contact Phone and/or Email

* 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 of Terms and Conditions


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