Children's Minneapolis Guest Stay Request

Overnight Stay Request Form

Children's Minnesota - Minneapolis Hospital

(999) 999-9999?999

Welcome to the Ronald McDonald House!

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 612-767-2781 or [email protected]

1. Stay Request

Arrival Date - Please select the date you would like to check into Ronald McDonald House (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

* Social Worker

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

* Date of Birth

Ethnicity

Diagnosis

Facility Treated At

* Inpatient - Hospitalized

* - Primary Language

* Unit - HIH

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

Add Another Patient / Twin

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

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

*County

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

* 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

* 3. Expected Stay Length

Less Than 7 Days

7+ Days

1 - 6 Months

Over 6 Months

Notes regarding this request:

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

Acceptance of Terms and Conditions

Select YES to complete your request.

An email will be sent, confirming we received this request.

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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.

Children's Minneapolis Guest Stay Request

Overnight Stay Request Form

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