Children's St Paul Guest Stay Request

Overnight Stay Request Form

Children's Minnesota - St. Paul Hospital



1. Stay Request


2. Patient Information



Unit

Unit



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

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. Do you want to continue?



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