Northland Guest Stay Request

Overnight Stay Request Form

Northland

Welcome to the Ronald McDonald House-Northland!

Social Workers are responsible for prescreening the family to ensure they meet requirements prior to completing this referral form; 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. The family will be contacted via RMH staff when/if a room is available for check in.

1. Stay Request

Arrival Date - Please select the date you want to check into Ronald McDonald House once they are inpatient.

Departure Date - Please select the date you think you anticipate them checking out of the Ronald McDonald House.

* 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. If the family has more than two patients, please add their name and information in Section 4 below.

* First Name

Middle Name

* Last Name

* Gender

* DOB

* Ethnicity

* Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

Insurance Company

Insurance Phone Number

MA Number

Patient ID Number

* Primary Language

* Unit - NLD

Add Another Patient

3. Guest Information

Please enter guests that are 18 years old or older. At this time, only parent/legal guardians are eligible.

* First Name

Middle Name

* Last Name

* Gender

DOB

* Relationship to Patient

* Email

* Cell Phone

Home Phone

* Country

*County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

Add Another Guest

4. Additional Information / Medical Billing / 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

Opt Out

* 2. Does your family receive any form of public assistance?

Yes

Opt Out

* 4. Insurance Information

Medical Assistance

Private Insurance

No Insurance

Combination

4b. County Social Worker

4c. County Contact Phone and/or Email

* 5. Have you called for preauthorization of lodging? (If NO, please call now)

Yes

* 6. Please enter preauthorization number or reason for denial

Notes regarding this request:

If you have more than 2 guests staying overnight, please enter their names, relationship to patient, and birthdate below.

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

Acceptance

Your request will be processed. The next step is that someone from Ronald McDonald House will review your request and our room availability and reach out to you.

Do you want to continue?

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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.

Overnight Stay Request Form

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