Self Referral

Ronald McDonald House Charities of Oregon & Southwest Washington

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 18+ will be screened against the National Sex Offender Registry.
Every guest must pass a health screening to ensure they are symptom-free.
Rooms allow 6 People max per family. Children under 24 months do not count towards total.

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

The patient is 21 or younger.
The patient and 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.

Screening Questions

* Is the patient being treated 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, protective 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 business hours.

Requestor Information

* 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 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

* Reason For Stay

* 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

* Hospital: OHSU Doernbecher, Casey Eye Institute, Randall Children's Hospital, Unity Health and Kartini Clinic 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.

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))

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

Reservation Information

* Your appointment date will be verified with the hospital.

* Date of first appointment at hospital

Appointment Time

* Check In Date

* Check Out Date

Guardian Contact Information

* Guardian/Caregiver Name (First and Last)

Guardian Preferred Name

Guardian Preferred Pronouns

* Relationship to patient

* 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

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

Emergency Contact Relationship

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

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

Self Referral

Ronald McDonald House Charities of Oregon & Southwest Washington

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

Guardian Contact Information

Second Guardian Information (Optional)

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