CT- H M I S AU T H O R I Z AT I O N F O R R E L E A S E O F I N F O R M AT I O N

Transcription

1 This authrizatin is vluntary. The infrmatin yu authrize us t disclse may be subject t re-disclsure by the recipient and if the persn r rganizatin authrized t receive the infrmatin is nt a health plan r health care prvider, the infrmatin may n lnger be prtected by Federal privacy regulatins. We may nt cnditin yur receipt f treatment, payment, enrllment, r eligibility fr benefits n cmpletin f this authrizatin. The Cnnecticut Hmelessness Infrmatin System (CT HMIS) is a shared system. This means that authrized Cnnecticut hmeless service Participating Agencies will enter yur infrmatin int the CT HMIS database. These participating agencies will have access t the infrmatin that yu agree t share. Sharing yur data allws Cnnecticut hmeless service prviders the pprtunity t see if they have husing services that fit yur needs. It des nt guarantee that yu will receive husing. Link fr list f participating agencies: click n Dwnlad File NAME (LAST, FIRST): DATE OF BIRTH: I hereby authrize the agencies listed belw t disclse infrmatin t and exchange the indicated infrmatin fr the purpse f ensuring effective crdinatin f services. PLEASE CHOOSE ONE OPTION HERE: I understand that with this shared system I have five ptins fr my and my child s persnal infrmatin. 1) By initialing here, I agree t ALLOW all f my and my child s infrmatin t be shared with all (initials) participating Agencies. I agree t share General Persnal Demgraphic, Husing and Sensitive Infrmatin Medical Histry, Mental Health, Criminal Recrd, Substance Abuse Histry included 2) By initialing here, I indicate that I ONLY want t share my and my child s infrmatin with Clumbus (initials) Huse. I agree t share General Persnal Demgraphic, Husing and Sensitive Infrmatin Medical Histry, Mental Health, Criminal Recrd, Substance Abuse Histry included 3) By initialing here, I want t LIMIT the infrmatin I share with ther agencies (cmplete bx belw). (initials) I understand that this Agency may nt deny me service if I d nt give them permissin t share my data with ther agencies. I als understand that my and my child s presence and needs will nt be knwn by any ther Participating Agency in the service system and that this may delay r limit my ability t access husing and service pprtunities frm ther Participating Agencies. IF YOU CHOSE OPTION 3 ABOVE, PLEASE COMPLETE THIS SECTION. I want I understand t limit the that infrmatin my infrmatin I share. may Chse be used ONE fr r research, BOTH ptins evaluatin belw: and advcacy. I will always be prtected by federal and state privacy laws. My persnal identity will never be part f any research reprts. A. By initialing here, I indicate that I d NOT want t share my and my child s infrmatin with the fllwing (initials) agencies: I agree t share General Persnal Demgraphic, Husing and Sensitive Infrmatin Medical Histry, Mental Health, Criminal Recrd, Substance Abuse Histry included (Please list r attach a list) B. By initialing here, I indicate that I d NOT want t share any f my and my child s sensitive* infrmatin (initials) with ther agencies. I agree t share General Persnal Demgraphic and Husing Infrmatin ONLY. *Sensitive infrmatin includes infrmatin n medical health, mental health, substance use, and criminal recrd.

2 I understand that my infrmatin may be used fr research, evaluatin and advcacy. This may include research prjects that match my needs with ther agencies r prgrams that may assist in getting me husing. I will always be prtected by federal and state privacy laws. My persnal identity will never be part f any research reprts. Staff f Clumbus Huse, Inc. have explained my rights with regard t the CT HMIS Prject t me and given me a written cpy f the explanatin. I can ask t see a dcument which lists the persns wh have updated my client recrd in the CT HMIS. If I have any cncerns abut hw my persnal data is being used r entered int the CT HMIS database I can cntact Ryan DeLach at x I understand that if I need hmeless assistance in the future, I will be asked t cmplete this cnsent frm again. I will be able t make a different decisin abut sharing r nt sharing my new data at that time. NOTICE TO RECIPIENT OF INFORMATION All r a prtin f this infrmatin may have been disclsed t yu frm recrds prtected by Federal and/r Cnnecticut state law which prhibits yu frm making any further disclsure f this infrmatin withut the specific written cnsent f the persn t whm it pertains, r as therwise permitted by said law(s). A general authrizatin fr the release f medical r ther infrmatin is NOT sufficient fr this purpse. In additin, Federal rules (42 C.F.R. Part 2) restrict any use f the infrmatin t criminally investigate r prsecute any alchl r drug abuse patient. I understand that this authrizatin will expire tw years frm the date I sign the authrizatin. I may revke this authrizatin in writing at any time; hwever, any revcatin will nt be effective retractively fr infrmatin disclsures that have already ccurred. Client Signature: Print Name I d nt want any identifying infrmatin entered int the data base. By checking this bx in indicate that I want my infrmatin t be kept annymus. Client Signature: Print Name Nte: If yu are a legal guardian r representative, yu must attach a cpy f yur legal authrizatin t represent the member and cmplete the fllwing: Signature f Guardian/Representative: Print: Legal Authrity: Staff: Check here if client refuses t sign. Data entry will be annymus, in rder t update in the future yu will need t recrd the client ID n the paper file and retrieve the recrd in that manner. Agency witness signature Print Name Date

3 If yu have any questins r need additinal infrmatin regarding this frm please cntact CCEH at r n line cceh.rg. Agencies that Participate in CT HMIS as f 9/25/2013 Area 1 - New Lndn Area Access Agency Alliance fr Living Bethsaida Cmmunity Inc. Cvenant Shelter Hly Family and Shelter Mystic Area Shelter and Hspitality New Lndn Hspitality Center Nrwich Human Services Perceptin Prgrams / Omega Huse Reliance Huse Sund Cmmunity Services Sutheastern Mental Health Authrity Thames River Family Prgram Thames Valley Cuncil fr Cmmunity Actin The Cnnectin United Services United Way Windham Reginal Cmmunity Cuncil Area 2- Danbury- Waterbury Area AIDS Prject Greater Danbury Ams Huse Assciatin f Religius Cmmunities (Dream Hme) Cathlic Charities f Danbury Center fr Human Develpment CCEH Rapid Re-Husing Charltte Hungerfrd Hspital Chrysalis Center Clumbus Huse - FUSE CREDO Danbury City Shelter Danbury Husing Authrity Drthy Day Hspitality Huse Family and Children's Aid Greater Danbury Shelter + Care Helping Hands Husing Authrity f the City f Danbury Independence Nrthwest MCCA New Milfrd Hmeless Shelter New Opprtunities Inc. Nn-Prfit Develpment Grup NrthWest CT YMCA Renewal Huse Salvatin Army Family Shelter St. Vincent DePaul Missin f Waterbury Trringtn Chapter f FISH Trringtn Y Limited Partnership Trringtn-Western Husing Optins Twn f New Milfrd Western CT Mental Health Netwrk Please review mst up-t-date list by clicking the Dwnlad File link at:

4 Area 3- Greater Hartfrd Area AIDS Cnnecticut (ACT) Capital Regin Mental Health Center Chrysalis Center Cmmunity Health Resurces Cmmunity Mental Health Affiliates Cmmunity Renewal Team Friendship Service Center Hands n Hartfrd Huse f Bread Human Resurces Agency f New Britain Immaculate Cnceptin Inter Cmmunity Mental Health Grup Judah Huse Manchester Supprtive Husing Mercy Husing and Shelter My Sister's Place Open Hearth Assciatin Salvatin Army - New Britain Salvatin Army Marshall Huse Suth Park Inn St. Philip Huse St. Vincent DePaul Missin f Bristl Tabr Huse Tri-Twn Shelter Services Western CT Assciatin f Human Rights YWCA f the Hartfrd Regin Zezz Huse Area 4 Fairfield Cunty Area ABRI Alpha Cmmunity Services Bridgeprt Rescue Missin Casa Inc. - Nble Huse Cathlic Charities f Fairfield Cunty DMHAS Family and Children's Agency Hall-Brke Hmes with Hpe Inspirica Laurel Huse Liberatin Prgrams Malta Huse, Inc. Mid Fairfield AIDS Prject NEON NEON-Nrwalk Open Dr Shelter (Nrwalk Emergency Shelter) Operatin Hpe Refcus Outreach Ministry Reginal Netwrk f Prgrams Shelter fr the Hmeless SuthWestern CT Mental Health Authrity Supprtive Husing Wrks The Cnnectin Please review mst up-t-date list by clicking the Dwnlad File link at:

5 Area 5- Middlesex Cunty Area Area Cngregatins Tgether BHCare Clumbus Huse - Middlesex Cmmunity Health Center, Inc. Cmmunity Health Resurces DMHAS/River Valley Services Mercy Husing and Shetler -Middlesex New Opprtunities - Meriden Rushfrd Center St. Vincent DePaul Place f Middletwn The Cnnectin - Eddy Center Wallingfrd Emergency Shelter Area 6 Greater New Haven Area APT Fundatin Beth El Center Beulah Heights Christian Cmmunity Actin Clumbus Huse Cmmunity Services Netwrk (CMHC) The Cnnectin, Inc. Cntinuum f Care Crdinating Cuncil fr Children in Crisis Easter Seals Gdwill Industries Emergency Shelter Management Services Fellwship Place Gibbs Restratin Huse Leeway Liberty Cmmunity Services, Inc. MACC Shelter Marrakech Inc. New Haven Hme Recvery Supprtive Husing Wrks US Department f Veteran Affairs WAGE Yuth Cntinuum Please review mst up-t-date list by clicking the Dwnlad File link at: