Self Referral

Ronald McDonald House Charities of Oregon & Southwest Washington

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 30 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.

Screening Questions

* Are you a patient at OHSU Doernbecher Hospital or Randall Children's Hospital?

* Is the patient diagnosis contagious?

* Is the patient still in utero?

* Are you a parent who is under 18 years of age?

* Do you or anyone else that will be staying in the house have any condition that could be potentially harmful to yourself or others, including current substance abuse?

* Are you or anyone that will be staying on the National Sex Offender Registry? (Please note our staff do run all party names against this list)

* Have you or anyone in your family been convicted of or are currently facing charges for a felony or violent criminal offense?

* Are you or anyone in your family currently involved with Child Protection Services or under investigation for child abuse, neglect, domestic violence?

* Are you party to a current restraining order or no contact order?

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

* Your Name

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

* Ethnicity (Used only for statistics in grant funding)

* Patient Gender

* Reason For Stay

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

* Assigned Social Worker/Hospital Staff (If unknown, choose "Unknown)

Physician/Doctor

* Department

* Hospital: OHSU Doernbecher, Casey Eye Institute and Randall Children's Hospital are the only facilities that we accept Self-Referral Requests from. For all other facilities listed, you will need to have your social worker complete a referral on your behalf.

* 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.

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 Information

* Date of first appointment at hospital

* Check In Date

* Check Out Date

Guardian Contact Information

* Guardian/Caregiver Name (First and Last)

Guardian Preferred Name

Guardian Preferred Pronouns

* Relationship to patient

* Ethnicity (Used only for statistics in grant funding)

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Primary Phone Number

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

* Email

Alternate Phone

Second Guardian Information (Optional)

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Ethnicity (Used only for statistics in grant funding)

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Primary Phone Number

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

Additional Guests / Family Members: Add Another Guest

Primary Language

Address
PO Box Addresses are not accepted

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.

* Emergency Contact Name

* Emergency Contact Phone

Additional Information

* 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

* Which of these describes your total household income? (This information is only used in securing grant funding for the Ronald McDonald House.)

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.

Each family will sign a stay agreement at check-in, and must be able to comply with the following guidelines.

Comments/Additional Needs