* To complete this request, you must have previously stayed at RMHC-KC in the past three years.
Please contact your hospital medical provider or hospital social worker if you need a request completed for a new guest stay.
* I understand that a room may not be available on the date of the requested check-in due to availability. Please call 816.541.8460 on your day of requested check-in.
Yes, I understand.
* The patient receiving evaluation and/or treatment is 21 years of age or younger?
* Do any members of the guest party have symptoms related to contagious illnesses?
* Does anyone in the guest party have a pending child abuse investigation or open child abuse and neglect case?
* Have you or anyone in your guest party been convicted of or are currently facing charges for a felony or violent criminal offense? (All guests over the age of 18 will have their IDs scanned upon arrival)
* Does anyone in the guest party have any felony charges or convictions?

Patient Information


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* Does the patient have Mediciad?
Medicaid if yes, brief description of what patient is being seen for
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

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Family Contact Information


U.S. / Canadian Postal Code lookup


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* Guardian Middle Name 
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Middle Name

Additional Guests

Additional Guests / Family Members

Add Another Guest

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.
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Additional Information for your stay

Family’s method of transportation to the hospital or our house?
* Will you have a vehicle on premises?
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* Does anyone in the guest party need a wheelchair accessible room?
* Any additional information you would like to add?