Children's St Paul Guest Stay Request

Overnight Stay Referral / Request Form

Children's Minnesota - St. Paul Hospital

(999) 999-9999?999

Welcome to the Ronald McDonald Family Room inside Children's Minnesota St. Paul.

Social Workers are responsible for prescreening the family to ensure they meet requirements prior to completing this referral form; click here to see the list of requirements in which a family would be eligible.

Please note: Rooms are not guaranteed & are assigned based on 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/reimbursement, please contact Crystal at 612-767-278 or [email protected].

1. Stay Request

Please complete all of the information in order for us to best serve the hospital partner and family.

Arrival Date - Please select the date the family would like to check into Ronald McDonald Family Room.
Departure Date - Please select the estimated check out date of the Ronald McDonald Family Room.

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

* Social Worker

2. Patient Information

This form currently only allows for up to two patients. If the family has more than two patients, please add their name and information in Section 4 below.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

Facility Treated At

* - Primary Language

* Unit - CFR

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 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

Approved

Denied

Pending

NA - Not Applicable

Insurance Contact Name

Insurance Contact Phone Number

Insurance Contact Email

Add Another Patient / Twin

3. Overnight Guest Information

Please fully complete for everyone who will be staying overnight. Overnight rooms are assigned to the parent/legal guardian. Children under the age of 18 must be supervised by a legal adult at all times while using the Family Room.

If you have more than 2 guests, please enter them in the notes in Section 4 below.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Relationship to Patient

* Email

Home Phone

* Mobile Phone

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

COVID-19 Information - At this time, the COVID-19 vaccine status does not affect eligibility

Vaccination Status

# Vaccinations

Vaccination Note

Add Another Guest

4. Additional Information

* 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

Your request will be processed. Do you want to continue?

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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 Referral / Request Form

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