Sample Policies and Forms

The below policies and forms may be used by RHCare agencies to ensure compliance with various certification requirements. To use, agencies must insert their own information where applicable and remove the sample watermark.

Sample Administrative Policies

Fiscal Policies and Procedures for Client Fees

Section B.5. of the RHCare Certification Requirements requires RHCare clinics to adopt fiscal practices that ensures clients receive the same level of reproductive health services regardless of their ability to pay. This sample policy provides procedures RHCare clinics may adopt to meet this requirement.

Mandatory Reporting

Section C.4. of the RHCare Certification Requirements requires RHCare agencies to maintain a written policy that requires clinic staff to follow state and federal laws regarding mandatory reporting and assists staff to recognize and acknowledge their responsibility to report suspected abuse or neglect of a protected person pursuant to Federal and State law. This sample policy was written in partnership with the Department of Justice to help RHCare agencies meet this requirement.

Policies and Procedures for Ordering, Controlling, and Storage of Medications and Devices

Section A.4. of the RHCare Certification Requirements require RHCare clinics to dispense medications and devices following Board of Pharmacy rules per appropriate licensure. This sample policy provides procedures for ordering, controlling and storage of medications consistent with Oregon State Board of Pharmacy rules as of April, 2023.

Sample Health History Forms

Providers should review a client's health history at the initial visit, and at least annually thereafter. Registered Nurses are permitted through the Board of Pharmacy’s CHC license to dispense birth control methods through standing orders. To ensure the necessary information is available for RNs to assess an individual’s health history, the RH program developed sample Initial Health History and Annual Health History forms.

Initial Health History	English	Spanish
Annual Health History	English	Spanish

Consent Forms

Consent for RH Services

Upon establishing care, clients/enrollees must sign a consent form for reproductive health services. The consent may be incorporated into the clinic's general consent for services, or it may be a stand alone form. To help clinics meet this requirement, we created the following sample consent forms.

English	Spanish
Korean	Marshallese
Russian	Simplified Chinese
Vietnamese

Consent for Insertions and Removals

RHCare clinics are required to obtain consent from clients before they undergo a medical procedure (i.e. insertion/removal of an IUC or implant). To help clinics meet this requirement, we created these sample consent forms. Clinics may also use the consent form included in each devices' packing. Either option is acceptable.

IUC Consent Form	English	Spanish
Implant Consent Form	English	Spanish