Children's St Paul Guest Stay Request

Overnight Stay Referral / Request Form

Children's Minnesota - St. Paul Hospital



1. Stay Request


2. Patient Information



* Unit - CFR



3. Overnight 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?

3. Expected Stay Length

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 reviewed.  Please check your emails for next steps.



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