Children's St Paul Guest Stay Request

Overnight Stay Request Form

Children's Minnesota - St. Paul Hospital

Welcome! We look forward to serving you. Below are a few items to know as you get started.

Qualifications for families and caregivers to be eligible to stay overnight at the Ronald McDonald Family Room at Children's Minnesota, St. Paul:

Have a patient admitted to the Children's Minnesota St. Paul Hospital.
Be actively involved in patient care to the extent possible.
Be at least 18 years old. Minors may stay overnight with a supervising adult present.

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 you want to check into Ronald McDonald Family Room overnight room (this is NOT your hospital arrival date)
Departure Date - Please select the date you think you may leave

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

Social Worker

2. Patient Information

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

* First Name

Middle Name

* Last Name

* Gender

* DOB

* Ethnicity

Facility Treated At

Unit

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

DOB

* Relationship to Patient

* Email

* Cell Phone

Home Phone

* Country

County

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

Add Another Guest

4. Additional Information/Medical Billing/Additional Guests

Ronald McDonald House Charities, Upper Midwest provides a temporary home-away-from home for families with seriously-ill children undergoing medical treatment. We are a non-profit 501(c)(3) public charity. It costs Ronald McDonald House Charities, Upper Midwest $165.00 per night to provide housing to each family at our Ronald McDonald House Northland location.

We currently seek to recover $60 per night in situations where families have medical assistance or private insurance to cover housing costs. Preauthorization is required from your insurance provider in order for us to bill.

If you dont have coverage for housing costs, we encourage a voluntary contribution of $25.00 per night to be made if you are able. However, any contribution is appreciated. No eligible family is ever turned away or asked to the leave because they are unable to make a financial contribution towards their stay.

Please call your county/state financial worker or member services to access your lodging/travel benefits and receive a preauthorization prior to checking into the Ronald McDonald House. Click here to find the contact number for your county.

* 1. Are you or any family members (grandparents, aunts, uncles, siblings) a Veteran or serving in the military?

Yes

Opt Out

* 2. Does your family receive any form of public assistance?

Yes

Opt Out

3. Expected Stay Length

Less Than 7 Days

7+ Days

1 - 6 Months

Over 6 Months

4. Insurance Information

Medical Assistance

Private Insurance

No Insurance

Combination

5. Have you called for preauthorization of lodging?

Yes

6. Please enter preauthorization number

7. County Social Worker

8. County Contact Phone and/or Email

Notes regarding this request:

If you have more than 2 guests staying overnight, please enter their names, relationship to patient, and birthdate below.

Also, 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

info@rmhtwincities.org

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.

Children's St Paul Guest Stay Request

Overnight Stay Request Form

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