Children's Minneapolis Guest Stay Request

Overnight Stay Request Form

Children's Minnesota - Minneapolis Hospital

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; click here to see the list of requirements in which a family would be eligible.

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 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

Staff

* 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

* 0. Insurance Info

Medical Assistance

Private Insurance

No Insurance

Combination

1a. Private Insurance Provider

1b. Private Insurance Phone Number

1c. Private Ins. Patient ID Number

1d. Private Ins. Group Number

1e. Have you Called for Pre-Authorization of lodging assistance? (If No, please call now)

1f. Please enter pre-authorization number for approval, or reason for denial / pending status

1g. Lodging Assistance Status

Approved

Denied

Pending

NA - Not Applicable

1h. Provider Contact Name

1i. Provider Contact Phone Number

1j. Provider Contact Email

1k. Lodging Notes

2a. MA Provider or County

2b. MA Provider / County Phone Number

2c. MA Number

2d. Have you Called for Pre-Authorization of lodging assistance? (If No, please call now)

2e. Please enter pre-authorization number for approval, or reason for denial / pending status

2f. Lodging Assistance Status

Approved

Denied

Pending

NA - Not Applicable

2g. MA Provider / County Contact Name

2h. MA Provider / County Contact Phone Number

2i. MA Provider / County Contact Email

Unit

* Unit - HIH

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

*County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

Add Another Guest

4. Additional Information / 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

* 3. Expected Stay Length

Less Than 7 Days

7+ Days

1 - 6 Months

Over 6 Months

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 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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