Guardian Contact Information
Please enter information for the guardian(s) who will be staying at RMHC.
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Family’s method of transportation to the hospital or our house?
Will you have a vehicle on premises?
Please enter car information below:
Please enter N/A below.
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Which of these describes your total household income? (Note: This information is only used in securing funding for the House.)
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Does the patient have Medicaid?
Does the patient have Private Insurance?
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If Private Insurance, who is your insurance provider? (type N/A if you do not have private insurance)
If there are no other rooms available, would you be able to accept a room with only 1 bed?