San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information
ABOUT RTFH HMIS AND 2-1-1 San Diego CIE: The San Diego County Homeless Management Information System (HMIS) managed by Regional Task Force on Homelessness (RTFH) and the Community Information Exchange (CIE) managed by 2- 1-1 San Diego are two separate databases that are used to provide referral services to social services agencies for individuals with healthcare, housing, food, transportation, financial, and other needs. This authorization will allow HMIS and 2-1-1 participating agencies to collect information from you and your care team to assess your needs and put you in touch with social services agencies (Participating Agencies) they work with. Information will be shared with those Participating Agencies that provide services that can address your needs to coordinate referrals and services, track your progress and evaluate our success, among other things.
We are committed to protect your information from unlawful disclosure. This Authorization permits a Participating Agency to re-disclose health information to another Participating Agency and the information may no longer be protected under applicable health privacy laws. However, even if the Participating Agency is not subject to health privacy laws, RTFH, 2-1-1 San Diego, and their Participating Agencies are still required to employ administrative, technical, and physical safeguards to protect all information collected under this Authorization and use and disclose information in accordance with federal and state law.
By signing this form I authorize and request the Regional Task Force on Homelessness (RTFH), 2-1-1 San Diego, and Participating Agencies that they may refer me to or who may already be providing me with services to collect, record, use, and share my personally identifiable health, financial, housing, employment, and other relevant information with each other in order to assess my healthcare, housing, financial, and other needs, and to coordinate my care and provide comprehensive services to me.
The types of information that may be collected, used, and shared pursuant to this authorization includes, without limitation, the following to be shared in both HMIS and CIE:
San Diego County CoC HMIS and 2-1-1 San Diego CIE Page 1 of 3 Multiparty Authorization to Disclose Information Version 1.1 Updated July 6, 2022
San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information
- Identifying Information: Name, age, date of birth, social security number, address, personal ID, race, ethnicity, gender, contact information and contact information for family members, spouse, and my personal representatives
- Housing: Current location, destination, period of homelessness, prior residence, and local assessment data related to housing
- Financial: Employer, employment status, income, and non-cash benefits • Military: Veteran status
- Health Information: Health and disability conditions and health insurance
- Sensitive Information: Drug, alcohol, and substance abuse, AIDS and HIV status, disabling conditions, developmental disabilities, mental health, and domestic violence information
Right to Decline or Revoke: I understand that I have the right to decline to share data or to revoke previous Authorization to share at any time by completing the Decline/Revocation form found at https://www.rtfhsd.org/about-coc/homeless management-information-system-hmis/ and sending it to RTFH at: support@rtfhsd.org or by mailing it to the Regional Task Force on Homelessness, 4699 Murphy Canyon Road, Suite 104, San Diego, CA 92123.
I also understand that I have the right to individually revoke my consent to share data within 2-1-1 San Diego CIE at any time by visiting https://ciesandiego.org/revoke/
Expiration/Renewal: Unless otherwise revoked, to the fullest extent allowed by law, this Authorization shall remain valid for seven (7) years from the Effective Date indicated below. This Authorization may be renewed with my written consent.
Other Rights: I understand that authorizing the disclosure of information is voluntary and I can refuse to sign. I do not need to sign this form to be assured of housing and/or health care treatment services or enrollment in a housing program or health plan. However, if this Authorization is required for RTFH, 2-1-1 San Diego, and the Participating Providers to provide coordinated referrals and services and if I do not sign this Authorization, then my receipt of housing or other services may be limited or delayed.
Right to a Copy of My Information: I understand that I may inspect or obtain a copy of the information to be used or disclosed from my providers.
San Diego County CoC HMIS and 2-1-1 San Diego CIE Page 2 of 3 Multiparty Authorization to Disclose Information Version 1.1 Updated July 6, 2022
San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information
Right to a Copy of this Authorization: I have right to receive a copy this Authorization.
Authorized Participating Agencies: The current list of Participating Agencies with whom RTFH and 2 -1-1- San Diego may share my information will be posted on the RTFH website:https://www.rtfhsd.org/about-coc/homeless-management-information system-hmis/ and on the 2-1-1 San Diego CIE website: https://ciesandiego.org/partners/.
San Diego County CoC HMIS and 2-1-1 San Diego CIE Page 3 of 3 Multiparty Authorization to Disclose Information Version 1.1 Updated July 6, 2022