Northland Guest Stay Request

Overnight Stay Request Form

Northland



1. Stay Request


2. Patient Information



Insurance Company

Insurance Phone Number

MA Number

Patient ID Number

* Primary Language

* Unit - NLD



3. Guest Information





4. Additional Information / Medical Billing / 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?

* 4. Insurance Information

4b. County Social Worker

4c. County Contact Phone and/or Email

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

* 6. Please enter preauthorization number or reason for denial


Notes regarding this request:



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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