Updated 8.12.2016

Oakland County HMIS

Client Release of Information

SECTION 1

This release of information is for the Michigan Statewide Homeless Management Information System (MSHMIS). Many shelters and agencies use the system to store information about clients that get help here.

The information you give:

May be used by other helping agencies in Oakland County.

Will help reduce the paperwork you would have to fill out at other agencies.

Will allow agencies to work together to better help you.


What helping agencies share information in the system?

Common Ground (limited to GAP) / South Oakland Shelter (SOS)
Community Housing Network (CHN) / Training and Treatment Innovations (TTI)
HOPE / Welcome-Inn/South Oakland Citizens for the Homeless (SOCH)
Lighthouse of Oakland County
Oakland Integrated Healthcare Network (OIHN)

The Michigan Coalition Against Homelessness may need to document your homeless history to see if you are eligible for specific community programs. Your case manager may contact a Representative from the Michigan Coalition against Homelessness (MSHMIS lead agency) to view data recorded in HMIS in order to complete a housing history document. With your permission, these representatives will complete the document and give it to your case manager. I give consent for the sharing agencies to be the recipients of this information by initialing here: ______

Sharing Options

Your information will be entered into the system, as this is our internal record keeping tool. All persons using the system are trained and certified in privacy. Your basic information (name, year of birth, partial SSN, gender, and veteran status) is searchable in the system by all HMIS licensed users. If you have a specific privacy concern, such as fleeing domestic violence, you may elect to close the search screen by initialing here: ______

If you have initialed above, please understand that your information will still be entered into the system but will not be searchable to other agencies. If you choose this option and have already received services from an agency in Oakland County, we will need to coordinate a discussion with those agencies to determine the most appropriate way to lock down the search screen.

Do you want to share your information with the helping agencies? Please initial the appropriate box.

Yes. I want to get help from any of the partner agencies as quickly as possible!
No. I want help, but I don’t want my info shared.

If No, your detailed information will not be shared but your basic information (name, year of birth, partial SSN, gender, and veteran status) will still be searchable in the system search screen. If you choose this option and have already received services from an agency in Oakland County, only the information from this date forward will not be shared with the other helping agencies.

Client Informed Consent and Release of Information Authorization

SECTION 2

Please read the statements below and place your signature on the Client Signature line below.

I have received a copy of the Michigan State HMIS Notice of Privacy Policies and Procedures that explains ServicePoint and my rights and responsibilities associated with the ServicePoint system.

I understand that this written consent allows the servicing agency to enter, see, and update information about my family and me in the MSHMIS.

I understand that the confidentiality of my records is protected by law. I understand that the servicing agency will never give information about me to anyone outside the agency without my written consent or as required by law (The regulations are the Federal Law of Confidentiality for Alcohol and Drug Abuse Patients, (42 CFR, Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CRF, Parts 160 & 164).

Page 1 of this document lists the Oakland County sharing agencies. All of the sharing agencies must follow strict privacy laws. The sharing agencies may change from time to time.

I understand that my photo will be viewable (when applicable) to the Oakland County sharing agencies listed on this agreement and give my permission for this image to be shared.

I understand that I have the right to see my detailed profile information, request to change it, and to have a copy of that information from the servicing agency by written request.

I understand that the information in this system will not be used to deny me services such as emergency assistance, outreach, shelter, or housing assistance.

I understand that this consent will automatically expire one year from the date of signature. Oakland County periodically participates in academic research with local and nationwide partners.

I understand that some of my protected personal information from the HMIS may be used for the academic research project but it remains confidential and protected by all parties.

Specific details about what is shared and who can see your information is in the attached Sharing Details document.

Client signature: ______Date: ______

Guardian or authorized representative signature (if required): ______

Relationship to client: ______

Guardian/authorized representative signature date: ______

Sharing Details

This document was developed to help explain what information is shared in HMIS and which agencies and projects can see your information. This document accompanies the signed ROI and is provided to the client prior to requested signature.

Agencies and projects that share my information:

-  Common Ground: Graduated Apartment Program

-  Community Housing Network (CHN): Chronically Homeless Leasing Assistance 1, Chronically Homeless Leasing Assistance 2, Chronically Homeless Leasing Assistance 5, Leasing Assistance Program 1, Leasing Assistance Program 2, Leasing Assistance Program 6, Leasing Assistance Program 7, Leasing Assistance Program CG, Shelter Plus Care Program, Rapid Rehousing Program, HARA ESG Screening, HARA ESG Rapid Rehousing, HARA ESG Prevention, Motel Vouchers, PATH Outreach, PATH Services, AmeriCorps, and Community Foundation Program.

-  HOPE: Emergency Shelter

-  Lighthouse of Oakland County: Chronically Homeless Leasing Assistance Program 2, Pontiac Apartments, Pontiac Houses, South Oakland, and Teen Program.

-  Oakland Integrated Healthcare Network

-  South Oakland Shelter (SOS): Emergency Shelter, After Care Program, Chronically Homeless Leasing Assistance Program 2, Chronically Homeless Leasing Assistance Program, Community ESG Services, Employment, Health Care, ESG Rapid Rehousing, SHIFT, and AmeriCorps.

-  Training Treatment Innovations (TTI): Shelter Plus Care Program, and Housing Leasing Assistance Program 1.

-  Welcome-Inn/South Oakland Citizens for the Homeless (SOCH): Warming Center

The basic information that is shared (a complete list varies by assessment and is available upon request):

Race / Homeless status / Disability
Ethnicity / Type of housing / Medical information
Your family members / Household income / Mental health
Your phone numbers / Domestic violence history / Substance abuse
Your address / Reasons for homelessness / Pregnancy status
Marital status / Employment information / Services provided
Military veteran status

Please note this document is subject to change and if you have concerns regarding the sharing of your information please contact your case manager.

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