Home away from home.

Ronald McDonald House Charities of Oregon & Southwest Washington

The following criteria must be met:

• Patients over 18 and caregiver(s) must pass regular screening criteria.
• Rooms can accommodate a maximum of 5 people.
• Every guest family member (including patient) must pass a daily health screening to ensure that they are symptom-free.
• Guests (if over 18) must sign "Stay Agreement" document at check-in.

Please share the following:
• RMHC staff will reach out to answer any questions about the House if a reservation is secured.
• All adult guests (18 and older) must present a picture form of identification upon arrival to the House. For the safety of our guests, all adults may be screened against the National Sex Offender Registry.

All families are placed “first come, first served”.
• Screening criteria apply to all adults (including patients) that are 18 or older and who will be staying at Ronald McDonald House (RMHC).
• Referral questions must be answered by or on behalf of all adults age 18 and older who will or may stay at RMHC within the next year.
• If one adult in the household does not qualify, it may disqualify the entire family from staying. Please contact staff at 541-318-4950 or bend.house@rmhcoregon.org for exceptions.
• Referrer must report any change in status that could be inconsistent with these criteria to RMHC. A family may be asked to leave if any criteria become a concern.
•All adult guests (18 and older) must present a picture form of identification upon arrival to the House.

PART I. Referrer questions: If the answer to any question in this section is “no”, the family does not qualify to stay at RMHC. If all answers are “yes”, proceed to Part II.

1. Is the patient a patient of a surrounding Bend area hospital or clinic?
2. Is the family able to function independently in a community-living environment?
3. For pregnant mothers only: Is the patient unborn and scheduled for delivery within two weeks? (Requires a doctor note emailed to bend.house@rmhcoregon.org.
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PART II. Family questions: If all answers to the following questions are “no”, proceed to Part III. If any answers are “yes”, or, if parental or domestic abuse is suspected in the patient’s injury or illness, do not refer the family to stay at RMHC and please notify our staff at 541-318-4950 or bend.house@rmhcoregon.org.

4. Do you have a history of perpetrating violence or abuse (physical, mental or sexual)?
5. Do you have a pending charge or a conviction of a crime against a child?
6. Do you have a history of erratic behavior, anger management issues, or any condition that could be potentially harmful to yourself or to others, including current substance abuse?
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PART III. Family Questions: If all answers to the following questions are “no”, proceed to submit a referral/reservation. If the answer to any question below is "yes", please contact our staff at 541-318-4950 or bend.house@rmhcoregon.org to discuss the potential of an exception. Please do not proceed without first talking to our staff.

7. Do you have a pending felony charge or have you ever been convicted of a felony?
8. Are you a parent under the age of 18? (All parents under age 18 must be accompanied by their parent or legal guardian. In certain cases, an adult relative over the age of 25 may substitute.)
9. Are you someone other than the parent or legal guardian of the patient (Pediatric only)?
10. Are you party to a current restraining order?
11. Is there an open child welfare case?
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Part IV: Confirmation

To the best of your knowledge, you are confirming the accuracy of the information above of all patients and guests who will be staying at RMHC and authorize the use and/or disclosure of protected health information from the treating hospital to RMHC for the purpose of accessing RMHC services. Disclosed information may include identifying information, patient diagnosis, reason for admission as well as other information pertaining to the patient's medical condition.

In order to stay at RMHC, family members must be symptom free of contagious illness:
• temperature of 100.4 F (38 C) or higher
• cough
• congestion or trouble breathing
• sore throat
• shortness of breath
• other flu-like symptoms (such as nausea, vomiting, diarrhea, chills, repeated shaking with chills, muscle pain, etc.)
• and not have been exposed to diphtheria, measles, mumps, chickenpox, whooping cough or shingles within 3 weeks of your check in, or TB within 3 months of your check in

Any questions? Contact our staff at 541-318-4950 or bend.house@rmhcoregon.org

Hospital Staff Information

* Your Name

* Phone

* Email

* Is the patient 21 years or younger?

Patient Information

Patient Name ( First and Last )

Patient Preferred Name

Patient Preferred Pronouns

* Patient Date of Birth (MM/DD/YYYY)

For Fetal Care patients, please put the child’s expected date of delivery

* Patient Gender

* Diagnosis (If unknown, enter in reason for visit: testing, trauma etc)

* Reason For Stay

* Department

* Social Worker/Care Management: (To add a new person, choose "Other")

Physician/Doctor

* Patient is being treated at:

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

Medicaid Information

While Ronald McDonald House Charities RMHC does not charge a fee or ask families to pay for their stay, we do work closely with state Medicaid to obtain lodging reimbursement for a family's stay. This funding helps RMHC ensure families are able to stay at no cost. If the patient is still in utero, the parents medicaid information can be entered in.

* Medicaid ID Number (If no Medicaid-Type in N/A, If you do not know your Medicaid ID-Type in Unknown))

* Medicaid Coordinated Care Organization/Transportation Brokerage (If no Medicaid, choose "No Medicaid")

Reservation Request

* Date of first appointment at hospital

* Check In Date

* Check Out Date

* Location: Choose Bend House for Pediatric Patients

Guardian Contact Information

* Guardian/Caregiver Name (First and Last)

Guardian Preferred Name

Guardian Preferred Pronouns

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Primary Phone Number

Do you consent to the guest service team contacting you via text? (message and data rates may apply)

Alternate Phone

* Email

Second Guardian/Caregiver Name (First and Last)

Guardian 2 Preferred Name

Guardian 2 Preferred Pronouns

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Relationship to patient

Primary Phone Number

Do you consent to the guest service team contacting you via text? (message and data rates may apply)

Additional Guests / Family Members: Add Another Guest

Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Additional Information

Please enter the name and phone number of someone who is NOT going to be staying at the Ronald McDonald House.

Emergency / Additional Contact name

Emergency / Additional Phone

* Will the family be bringing a service dog? (companion and emotional support dogs do not qualify as service animals and are not allowed at our Houses)

No Yes

* Does the family require an ADA Room?
We will do our best to accomodate, this is not guaranteed. Please reach out to the guest service team to check on availability after you submit your request. Bend.house@rmhcoregon.org.

Comments / Additional Needs