Northland Guest Stay Request

Overnight Stay Request Form

Northland



1. Stay Request


2. Patient Information



* - Primary Language

* 0. Insurance Info

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

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

2g. MA Provider / County Contact Name

2h. MA Provider / County Contact Phone Number

2i. MA Provider / County Contact Email

* Unit - NLD



3. Guest Information






4. Additional Information / 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?


Notes regarding this request:



Acceptance

SELECT YES to complete request.

If request was successfully submitted, you will receive a copy in your email inbox.



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