Children's St Paul Guest Stay Request

Overnight Stay Referral / Request Form

Children's Minnesota - St. Paul Hospital


1. Stay Request


2. Patient Information


* - 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.
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


3. Overnight 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?

Notes regarding this request:



Acceptance

Select YES to complete your request.

Your request will be reviewed. 

Please check your emails for next steps.



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