Return Family Self Registration

Ronald McDonald House Charities of Oregon & Southwest Washington

Return Family Request Guidelines

Check in Date

· You can check-in up to 1 day prior to your appointment.

· You cannot complete your reservation without a specific date. Please do not start your reservation until you have a confirmed medical appointment.

· You can reserve a room up to 30 days in advance.

· Non-hospitalized patient appointments must be no more than 2 days apart.

· You cannot make a same day reservation. If you are requesting to stay starting on the current date, please enter tomorrow’s date as your check-in date. Contact Family Placement after you enter in your request (971) 230-6702.

Check out Date

· If your child is admitted to the hospital, we recommend that you choose a check out date further than anticipated.

· You may make a reservation for up to 3 months. Longer stays can be considered, depending on availability.

· Check out is before 12:00pm.

Notifications

· All guests (18 and older) must present a picture form of identification upon arrival at the House.

· For the safety of our guests, all adults will be screened against the National Sex Offender Registry.

· Every guest family member (including patient) must pass a health screening to ensure they are symptom-free.

· Rooms can accommodate a maximum of 6 people.

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

· The patient is 21 or younger.

· The family resides 50 or more miles away from the treating hospital.

· All family members must be free of contagious illness.

· The family can function independently in our community living environments.

If you need assistance making a reservation with us, click on the Request Help button in the right-hand corner above, and our Family Placement Team will call you within 24 hours.

Requestor Information

* Name of Person Filling Out this Request

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

* Patient is being treated at:

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

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

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

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.)

Oregon Health Plan OHP 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 (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?

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.

Reservation Information

* Date of first appointment at hospital

Appointment Time

* Your appointment date will be verified with the hospital.

* Check In Date

* Check Out Date

Guardian Contact Information

For return families, please ensure you are adding all Guardian/Guest's 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

Family Information

Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

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.

Emergency / Additional Contact name

Emergency / Additional Phone

Emergency Contact Relationship

* 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