HMIS ROI

IL-518 CoC Client Release of Information and Sharing Plan

Agency Authorized to Share: Project NOW

This Agency collects information about people who apply for services. When we meet with you, we will ask you information about you and your household. We will put the information into a computer system called the Homeless Management Information System (HMIS The information that we collect allows us to work with other Participating Agencies (agencies that use the HMIS) in the CoC to help you, to coordinate your case management, and to reduce the number of times that you have to re-tell your story or repeat your information.

Choose ONE of the following sharing options by checking the box next to your choice:

Option 1: This option allows the most information sharing, and therefore the most coordination of services and the least duplication of efforts in order to serve you.

Your basic information will be shared with all agencies using the HMIS. Basic information includes your name, date of birth, social security number, program enrollments, case managers, military background (veteran Status) and photo.
Your detailed information will be shared with agencies in the Northwestern Illinois, and includes the other information that you choose to share with us, including your healthcare and drug treatment information.

Please see the IL-518 CoC Sharing Plan (or “Sharing Plan”) for a complete list of the information shared, and the local agencies with which it is shared. The agencies who participate in the Sharing Plan may change from time to time, but you can always obtain the most recent copy of the Sharing Plan from the Agency upon request.

I authorize the Agency to share my Basic information among all Participating Agencies, and to share my Detailed information with local agencies.

Option 2 : Under this option, only the Participating Agencies that you list below will be able to see your Detailed Information, including your healthcare and drug treatment information.

I authorize the Agency to share my Detailed Information with ONLY the following Agency(s):

I authorize the Agency to share my Detailed Information with ONLY the following Agency(s)

Option 3: Under this option, your information will not be shared, and you will not be denied access to services because you chose not to share.

I do not authorize the Agency to share my information.

Notice Regarding Disclosure of Healthcare and Drug Treatment Information

If you choose to share your information under Option 1 or Option 2 of this release, the shared information may include information about your physical and mental health, communicable diseases and venereal diseases such as, hepatitis, syphilis, gonorrhea, tuberculosis, HIV/AIDS, and your drug and/or alcohol abuse and treatment history. If you do not wish to share this information, you should choose Option 3, which states “I do not authorize the Agency to share my information.” If you choose to authorize sharing, we will only share your healthcare and drug treatment information according to the sharing option that you choose on this form.

I understand that this Release will remain in effect for five 5 years, after which, I will need to sign a new release if I wish to continue sharing my information. I can revoke this release at any time before it expires by notifying the Agency in writing. I understand that I can refuse to provide any information that is requested from me and that I will not be denied services based on my refusal to answer a question, unless the answer is necessary to determine if I am eligible for the services I have had an opportunity to ask questions about HMIS, and I may review a copy the IL-518 CoC Privacy Policy, IL-518 CoC Privacy Notice to Clients, and the Sharing Plan upon my request. No one has offered me anything in exchange for signing this document. I have read it, I understand it, and I sign it under my own free will.

Client Printed Name*

First NameLast Name

Client Date of Birth*

Date

Client Signature*

Client Social Security Number*

Date*

Date

Type a question

	First and Last Name	Date of Birth (MM/DD/YYYY)
Dependent 1
Dependent 2
Dependent 3