Northland Guest Stay Request - RMHC Upper Midwest

Overnight Stay Request Form

Northland

(999) 999-9999?999

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.

Anyone with an infectious disease or who recently has been exposed to an infectious disease, is not be eligible for services at Ronald McDonald House Charities Upper Midwest.

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.

If you have questions regarding medical preauthorization/reiumbursment, please contact Crystal at 612-767-2781 or [email protected].

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

* Social Worker

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

Ethnicity

* Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

- Primary Language

Doctor/Department Phone Number

Doctor Name

Provider Type (Neonatolgy, Nephrologist, etc.)

Purpose of Visit/Hospitalization

Appointment/Admission Date/Time

* Unit - NLD

Insurance Provider

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.

Medical Assistance

Private Insurance

No Insurance

Combination

Insurance Phone Number

Patient ID Number

Group Number

Lodging Assistance Status

Approved

Denied

Pending

NA - Not Applicable

Insurance Contact Name

Insurance Contact Phone Number

Insurance Contact Email

Insurance Notes - If you or your county/state and/or member services have any questions about preauthorization/billing, please contact RMHC-UM staff member, Crystal Blank at 612-767-2781 or [email protected]

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

* Date of Birth

*Relationship to Patient

Contact Information

* Email

Home Phone

*Mobile Phone

* Country

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

*County

Add Another Guest

4. Additional Information / Additional Guests

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

Notes regarding this request:

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

Acceptance

SELECT YES to complete request.

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

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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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