Northland Guest Stay Request

Overnight Stay Request Form

Northland


1. Stay Request


2. Patient Information




* - Primary Language
* 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.
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







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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