Jason Burns

Samantha Bochinski

HMIS Administrator Department of Planning Division of Neighborhood Improvement

HMIS Program Liaison Department of Planning Division of Neighborhood Improvement

HMIS Client Consent Form HMIS (Human Management Information Systems) is a computerized record keeping system that captures information and the service needs of people experiencing homelessness and other public service needs. ___________________________________ (“Agency”) uses HMIS as their data management tool to collect information on the clients they serve and the services they provide. This system benefits you because you will not have to complete an additional intake interview should you need further services. Upon your consent, the information you share includes, but is not limited to, your first name, last name, social security number, date of birth, race, ethnicity, income, benefits, and disabilities. The information shared with the collaborating agency or agencies will be used to help you access services that will help you obtain and/or maintain permanent housing. Your written consent allows our agency to share your intake information with any collaborating agency. You have the right to request information about who has viewed or updated your HMIS record. You have a right to receive a copy of this Consent Form and the HMIS Privacy Notice. Agency has an interagency sharing agreement with the collaborating agency or agencies regarding clients that are served by such agencies. The agencies also have an agreement with the CoC HMIS Lead Agency, who has completed security procedures regarding the protection and sharing of client data. These agencies may also use your information, without any identifying information, for reporting requirements and advocacy.           

HMIS is a web based information system that homeless service agencies and prevention agencies across the United States of America use to capture information about the persons they serve. The Agency uses HMIS to assess needs of clients, help agencies plan to have appropriate resources, to inform the public, and create a case for program funding. Only licensed HMIS users may view, enter, or edit client records. No information will be released to another agency without signed client consent. The client has the right to have their information removed, and may refuse to answer any question, unless entry into a program requires it. Information that is transferred over the web is through a secure and encrypted connection. Case managers may use HMIS to inform clients what services are offered on site or by referral through the assessment process. The case manager and the client may use information to assist the client in obtaining resources that may fulfill client needs. No client record may be shared electronically without signed client consent. A client must be informed what information is being shared and with whom it is being shared. The Agency will uphold Federal and State confidentiality regulations to protect client records and privacy. The Agency will not solicit or input information from clients unless it is essential to meet minimum data requirements, provide services, or conduct evaluations or research. The Agency may not use any client information for marketing purposes.

By signing and consenting, you authorize Agency:  To share your intake information with collaborating HMIS licensed agencies to be used for an initial intake assessment.  To provide basic demographic information, residential, employment/income, military/legal, service needs, goals and outcomes.  To allow your information to be shared electronically via a secure, encrypted, web-based system to the collaborating agencies.  To allow your records and information to be shared for a period of no greater than three years (3) from today’s date. I, ____________________________________________________ Client Signature Consent Do Not Consent

_________________________ Date

To having my information (demographic, residential, employment, income, military, legal, services, and goals and outcomes) that I provided in intake interviews to staff at Agency to be shared electronically with the collaborating agencies using the HMIS. This also includes my medical, mental health, and/or substance abuse history information that I provide to the Agency. I understand that Agencies must comply with HIPAA and MCMRA regulations when sharing. I understand that I may request my information be removed from HMIS at any time.

______________________________________________________ Agency Staff Signature

_________________________ Date

NOTE: All adult household members must sign their own consent form(s), and must be placed into the family file. If children under 18 are benefiting from agency services, please write their names on the back of this form, along with their relationship to this client.

105 West Chesapeake Ave, Suite 201, Towson, MD 21204 ● P: (410) 887-5968 ● [email protected]