Oak Street Guest Stay Request

New Family Registration / Stay Request

Oak Street

1. Stay Request

2. Patient Information

- Primary Language
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 Provider
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
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]

3. Guest Information

4. Additional Information

* 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?
* 3. Expected Stay Length

Notes regarding this request:

Criminal History Background Check Authorization

Thank you for your inquiry to stay Ronald McDonald House Charities-Upper Midwest Oak Street. We hope to assist your family during this challenging time.

Ronald McDonald House Charities-Upper Midwest (RMHC-UM), in order to undertake reasonable efforts to protect the safety of the guest families residing with us, now requires that each individual applicant (age 18 or older) who applies to stay at Ronald McDonald House Oak Street to undergo a formal inquiry into their background (background check) to assess whether the guest applicant should not be permitted access to our facilities. This background check will include a private, multijurisdictional database of criminal records, as well as, a search of the National Sex Offender Public Registry for each individual age 18 or older, and will be re-run every 6 months while staying at RMHC-UM or upon a return visit.

All guest applicants are required to go through this process. You have the right to decline to have this background check performed. However, if you do decline the background check, we will have no choice but to deny your request for access to our facilities out of the need to take all reasonable efforts to protect the safety of our families. Please understand that RMHC-UM solely will obtain a background check to assist it in determining whether to grant you access to our facilities. RMHC-UM is not obtaining a consumer report for any other purpose. RMHC-UM will not be conducting a credit check. By accepting this authorization, you authorize us to obtain the background report described in it from a consumer reporting agency.

This background check will be conducted by a third party. Results of the background check are sent directly to RMHC-UM. The information obtained during the background check process will only be used by RMHC-UM to determine whether to grant access to our facilities and will only be divulged on a need to know basis to those individuals or entities that it deems necessary to review that information. The information will not be disclosed for any other reason. In order to protect the health, safety and welfare of our guest families, an individual will fail the background check if they have a history of criminal activity that violates the  RMHC-UM policy:

RMHC-UM reserves the right to refuse admittance to any potential resident or guest with a criminal conviction. RMHC-UM does not admit anyone with a criminal conviction that may threaten the health, safety, welfare and ability of other individuals to peacefully enjoy the House (e.g. violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, burglary, robbery, theft or fraud.

RMHC-UM also will not admit any individual who provides false, incomplete, or misleading responses during the formal criminal history background check.

If you have failed the background check, you will need to find other accommodations. Other individual members of your family/group, who pass the background check may be permitted access to our facilities with a passing background check. The background check will be performed by MBI Worldwide The tollfree telephone number that you can use to contact MBI Worldwide is 1866275-4624. MBI World wides address is 200 Central Ave Suite 820 St. Petersburg, FL 33701 United States. You have important rights under the Fair Credit and Reporting Act that you can exercise by contacting MBI Worldwide. If MBI Worldwide reports negative information to us causing you to fail our background check, you can obtain a copy of your report from MBI Worldwide free of charge. You can dispute any inaccurate, incomplete, or outofdate information in MBI World wides Report by contacting MBI Worldwide. If you do, MBI Worldwide will reinvestigate the information that you dispute, remove or correct any inaccurate or incomplete or outofdate information, and send us a replacement report. MBI Worldwide will also take steps to prevent any inaccurate or incomplete or outofdate information from appearing in any future reports they prepare about you.

In addition to this policy, RMHC-UM reserves the right, in its sole discretion, to expel a guest for any inappropriate, irresponsible or criminal behavior that takes place while temporarily residing at one of our Houses. While RMHC -UM has implemented this background check policy in order to take reasonable efforts to protect the safety of our guest families, RMHC-UM cannot and does not warrant or guarantee the personal safety of any temporary resident, guest, visitor or staff member.

Please confirm that you have read and understood the above


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