Northland Guest Stay Request

Overnight Stay Request Form

Northland



1. Stay Request


2. Patient Information



MA Number

Primary Language

* Unit - HIH



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?

* 3. Expected Stay Length

* 4. Insurance Information

* 5. Have you called for preauthorization of lodging?

* 6. Please enter preauthorization number

7. County Social Worker

8. County Contact Phone and/or Email


Notes regarding this request:



Acceptance

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?



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