Children's Minneapolis Guest Stay Request

Overnight Stay Request Form

Children's Minnesota - Minneapolis Hospital

1. Stay Request

2. Patient Information

* - 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.
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

3. Guest Information - 18 or Older

4. Additional Information

* 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

Notes regarding this request:

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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