Guest Referral Form
This referral can be submitted up to 30 days in advance of any scheduled appointment. This referral does not automatically guarantee eligibility or room availability. Families may call up to 48 hours in advanced to confirm room availability. Phone Number: (850) 477.2273
Patient's Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Reason for Visit:
*
Asthma and Allergies
Auto Immune
Behavioral
Blood Disorder (Hematology)
Cardiac
Ear Nose & Throat
Endocrinology
Gastroenterology/Digestive
High-Risk Pregnancy
Infection
Neurology
Oncology
Optometry
Orthopedic
Premature Birth
Pulmonology (Respiratory care)
Trauma ( MVA, Brain Injuries, accidents, etc.)
Urology
Medication Withdrawal
Other
Physician Providing Care
*
HealthCare Facility
*
Studer Family Children's Hospital
Nemours Children's Specialty Care
Child Neurology Center
Baptist
Andrews Institute for Orthopedics
The Eye Institute
West Florida Hospital
Other
Admission or Appointment Date & Time (set as 12 am if not a scheduled time)
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Anticipated Length of Treatment
Patient covered by Medicaid
*
Yes
No
Medicaid Plan
Please Select
Aetna
CMS
Humana
Simply
Sunshine
United
Unknown
Select Medicaid Plan(s)
*
Humana
Sunshine
Simply
United
Aetna
Medicaid / Humana Patient ID #
*
if patient does not have Medicaid, please type 000
Humana Patient ID #
Starts with "H"
Referring Staff Name
*
Referring Staff Contact Number
*
Format: (000) 000-0000.
Primary Parent/Legal Guardian
*
First Name
Last Name
Best Contact Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Notes / Reason for stay (appt, surgery, in-patient)
Example: Multiple patients, Adoptive family, Child discharged, Traveling from afar, Etc.
Is this referral for a stay at our House location or Family Room?
Ronald McDonald House
RMH Family Room
Diagnosis
Medicaid Plan
Not Applicable
Humana
Sunshine
Simply
United
Aetna
Other
Please assign guest a room
Room 1 (Closest to Guest Computers)
Room 2 ( Middle)
Room 3 ( Closest to Exit )
Submit
Print Form
Should be Empty: