Northland Guest Stay Request

Overnight Stay Request Form


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:


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?


This template controls the elements:

FOOTER: Footer Title, Footer Descriptions

* This message is only visible in administrative mode