Return Family Self-Referral

Ronald McDonald House Charities of Oregon & Southwest Washington

Notifications

Reservation requests may be submitted no more than 30 days ahead of your check-in date.
You may request to check-in the day before the patient's appointment. You must check out by 12 pm the day after a patient's appointment.
If you are discharged early, you have until the next day by 12 pm to check out. (If you want to request an exception to stay longer after being discharged, please call Family Placement at 971-230-6702.)
All guests 18+ must be prepared to present photo ID upon arrival at the House.
All guests 18+ will be screened against the National Sex Offender Registry.
All guests must be free of contagious illness before arrival.
Rooms allow 6 People max per family. Children under 24 months do not count towards the total.
Only 1 room per family is allowed.

To qualify to stay, the following criteria must be met:

The patient is 21 or younger.
At East House in Portland, the patient and guardian must live 30 or more miles from the facility where they are receiving care. (Portland only)
At South Waterfront House in Portland, the patient and guardian must live 50 or more miles from the facility where they are receiving care. (Portland only)
The patient is either admitted to the hospital or has medical appointments no more than 48 hours apart.
The family can function independently in our community living environments.

Name of person making this request

* Your Name

Patient Information
To add additional patients, enter the information in the Additional Guests / Family Members section below and select the ‘patient’ relationship.

* Patient Name ( First and Last )

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

* Patient Gender

Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Patient Medicaid and OHP 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 (Oregon Health Plan OHP, Washington, Alaska and Idaho 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 or a newborn, the parents medicaid information can be entered in.

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

Oregon Health Plan OHP Medicaid Coordinated Care Organization/Transportation Brokerage (If no Medicaid, choose "No Medicaid")

Is your Medicaid Transportation and Lodging Brokerage one of the following? Translink, Ready Ride AllCare, or Cascades East Transit?

Reservation Information

* Check In Date

* Check Out Date

RMHC will verify appointment/treatment dates with the hospital. Please enter the date/time of first appointment or hospital admittance.

* Date of first appointment at hospital

Appointment Time

* Diagnosis Category (If unknown/not listed, choose "Other")

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

Assigned Social Worker/Hospital Staff (If unknown or you do not see your social worker's name, choose "Other" at the very bottom of the dropdown menuand enter in "Unknown" or your social worker's name.)

* Department (If unknown/not listed choose "Other")

* Patient is being treated at:

Will the patient be inpatient or outpatient?

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

*Inpatient refers to Hospitalized patients. Outpatient refers to Non-Hospitalized patients.

Guardian Information

For return families, please ensure you are adding all Guardian/Guests on this request, otherwise their referral status will not update and they will need to do another referral with us before they can check in.

* Guardian/Caregiver Name (First and Last)

* Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

* Relationship to patient

* Primary Phone Number

Do you consent to Family Placement contacting you via text? (message and data rates may apply)

Alternate Phone

* Email

Second Guardian Information (Optional)

Second Guardian/Caregiver Name (First and Last)

Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Relationship to patient

Primary Phone Number

Additional Guests / Family Members: Add Another Guest

Additional Information

Emergency Contact

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

If your emergency contact or guest information has not changed since your last stay, you do not need to fill this out again.

Additional Emergency Contact Name

Additional Emergency Contact Phone Number

Relationship with patient

Will you be parking a car with us during your stay?

Car Make/Model/Description

Car License State

License Plate#

Will your family be bringing a service dog? (companion and 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 family placement to check on availability after you submit your request. Family@rmhcoregon.org.

Does the family require a room with a kitchen? (Only applies for East House Location and is prioritized for patients who are immunocompromised)
We will do our best to accomodate, this is not guaranteed. Please reach out to family placement to check on availability after you submit your request. Family@rmhcoregon.org.

If OHSU South Waterfront House is full, would you like to be considered for a room at our East House located at 2620 N Commercial Ave? This location is a 15 min drive from OHSU.

Comments / Additional Needs