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Sample Policies, Protocols, Forms, and other Clinic Materials

The below policies and forms may be used by RHCare and CCare agencies to ensure compliance with certification requirements. Please note these are sample templates only and clinics are not required to adopt these policies or tools. 

Agency leadership is responsible for reading all documents thoroughly, ensuring that the policies and practices described align with the actual practices of the agency/clinics, and for providing relevant training. The resources may be edited as needed; however, agencies are responsible for ensuring any changes meet all state, federal, and programmatic requirements. All highlighted areas of the sample tools should be filled in with the agency- or clinic-specific information. 

Sample Policies

These policy templates have been created to help agencies meet RHCare and CCare certification requirements. They should be reviewed and signed by agency leadership to ensure that the policies and practices described align with the actual practices of your agency/clinics.

Policy Name

Relevant to RHCare

Relevant to CCare

Clinical Lab Services
✔
✔
HIPAA
✔
✔
Infection Control
✔
✔
Medical Emergencies
✔
✔
Pharmacy Dispensing
✔
✔
Pharmacy Ordering
✔
✔
Minor Consent
✔
✔
Mandatory Reporting
✔
✔
Quality Improvement
✔
Fiscal
✔

Sample Forms

These editable forms can be used or adapted to meet your clinic needs for health history forms, screening tools, and consent forms.

Clients should fill out the initial health history form at their first visit to your agency.

​ An age appropriate screening tool should be given along with the health history.

    ​Clients' health histories should be updated annually. This can be done verbally or by having them fill out a form. You may wish to repeat the screening tools (see above) on a routine basis as determined by your clinic.

    Upon establishing care, all clients are required to sign a consent form stating that they understand RH services are voluntary.

    ​If your agency already uses a general consent form for services, here is some sample language you can incorporate to meet this requirement.
    • Sample RH Consent Language - English
    • Sample RH Consent Language - Spanish​

    Sample RN Protocols

    The purpose of the RN protocols is to provide certified agencies with a sample that supports nursing practice and helps standardize care in accordance with the relevant Clinical Practice Standards. Clinics may customize and adopt these following their agency’s internal process and in accordance with Oregon State Board of Nursing rules. Clinics are not required to conduct RN contraceptive visits; however, for those that do, it must occur under an RN protocol signed by a prescribing provider.


    Other Clinic Materials


    Sample Patient Bill of Rights

    This is a customizable 8.5 x 14" patient bill of rights that can be printed and posted in your clinic. There is a color and a black and white version in English and Spanish. We strongly recommend these to be posted at each clinic, or you can create your own bill of rights.

     English Black and White

     English Color

     Spanish Black and White

     Spanish Color


    Health Education Materials

    Please go to our Health Education Materials Ordering & Downloading page to find resources like our pregnancy options brochure, RH brochure, birth control brochure, etc.