The AIDS Service Organization Collaboration (ASOC)

Austin ServicePoint Homeless Management Information System Authorization to Use and Disclose Confidential Protected Health Information (PHI) And Protected Personal Information (PPI)

The Austin Homeless Management Information System (HMIS) is composed of independent homeless service provider organizations of the Austin community that are working to improve the lives of homeless persons and families while working toward the goal of ending homelessness in the Austin community. Currently participating HMIS Agencies are listed in this form. The number and identity of HMIS Agencies may change from time to time, but the information you authorize to be disclosed through this Authorization will only be disclosed to those agencies you have indicated. The goal of the HMIS is to better coordinate health and supportive services to homeless persons of our community, to overcome barriers to referral and linkage faced by persons who are homeless and to implement appropriate support and case management assistance. Participating HMIS Agencies may need to share confidential protected personal information (PPI) and protected health information (PHI) among themselves. In this Authorization, PPI and PHI are referred to together as “Confidential Information.” Disclosure of any Confidential Information between HMIS Agencies will require your signed authorization. If you agree to authorize the use and disclosure of your Confidential Information and/or that of any other person to whom you are a parent or guardian among HMIS Agencies, as described in this form, please sign below and mark each type of Confidential Information and each HMIS Agency that this Authorization applies to.

I ______authorize employees of (Name)

______(Disclosing Agency) to use, release, and disclose the Confidential Information of those persons listed below for the purposes set forth in this Authorization, to other Austin HMIS Agencies and their employees, and health care providers, to the extent that they are designated below.

I understand that “Confidential Information” includes each of the following that I have indicated that is housed in any of the records of the Disclosing Agency. (THIS AUTHORIZATION MAY BE USED TO AUTHORIZE THE CONFIDENTIAL INFORMATION OF MORE THAN ONE PERSON ONLY IF THE CONFIDENTIAL INFORMATION TO BE AUTHORIZED IS IDENTICAL FOR EACH PERSON:

Basic Identifying Information (name, age, social security number Additional Profile Information (includes gender, race, marital and family status, household relationships, emergency contact information, if released from Public Institution to homeless situation, duration homeless, shelter stay infractions) Residential/housing Information (includes address) Military history/Veteran status Legal History (includes citizenship/immigration/arrest/ conviction) Case management plans/goals/notes Services provided/service history Personal Strengths Assessment Client Budget and Expenses Assessment Employment Assessment (includes work history/current income/public assistance received) Medical Assessment (includes diagnosis/disability/medication) Mental Health Assessment (includes diagnosis/assessment/treatment history/medication) Children Assessment (includes caregiver/immunization/school status/special medical needs/diagnosis) Determination of Mental Retardation Insurance Information HIV/AIDS Information Substance Abuse Information Other, (Please Specify):

Shared by Austin Travis County MHMR, Austin, TX on HMIS.info Universal Consent Form I authorize the release and disclosure of the above-indicated Confidential Information to the Austin HMIS Agencies and any other entities indicated below (THIS AUTHORIZATION MAY BE USED ONLY IF THE AUTHORIZED HMIS AGENCIES ARE IDENTICAL FOR EACH PERSON LISTED BELOW):

AIDS Services of Austin Foundation for the Homeless Austin Travis Co. Health and Human Services Homeless Health Clinic - ARCH

Austin Travis Co. MHMR Housing Authority/City of Austin

Basic Needs Best Single Source Housing Authority/Travis County

Crime Prevention Institute LifeWorks

Front Steps/ARCH Marylee Foundation

Community Advocates for Teens Marywood and Parents Push Up Foundations Community Partnership for the Homeless Passages Program

Crime Prevention Institute Salvation Army Social Services/Shelters

Caritas of Austin SafePlace

Casa Marianella/Pasada Esperanza Vincare/St. Louise House

City of Austin Community Court Other

Family ElderCare I UNDERSTAND THAT I AM NOT REQUIRED TO SIGN THIS AUTHORIZATION, AND THAT IF I DO NOT WANT THIS INFORMATION DISCLOSED, MY OPTION IS NOT TO SIGN THIS AUTHORIZATION. If I sign this Authorization, such information may be received, used, and disclosed by the entities I indicate in this Authorization as authorized by state and federal law.

Confidential Information may be sent and received through telephone lines and stored in a secure encrypted centralized HMIS database called ServicePoint, operated by Bowman Internet Systems in Shreveport, Louisiana. By signing this Authorization, the Disclosing Agencies is allowed to make the Confidential Information available through this Internet database system, but only to those recipients designed above (and their employees) and health care providers affiliated with those HMIS Agencies for continuity of care, disease management and/or health care operations, including but not limited to quality assessment and improvement and program evaluation. I understand it may take approximately two weeks after I submit this signed Authorization before the Confidential Information is available as requested in this Authorization. ______I understand that I have the right to revoke this Authorization at any time, with respect to either some or all of the persons listed below whose Confidential Information is affected, except to the extent that the Disclosing Agency

Shared by Austin Travis County MHMR, Austin, TX on HMIS.info 2 Universal Consent Form has already acted in reliance on it. Revocation will stop the release of future information only. Past information I previously consented to release, will not be retrieved from agencies that received the information. Revocation must be in writing and mailed or hand delivered to the Disclosing Agency, and must include the date and purpose of the Authorization, a statement that I want to revoke it and a list of the persons named in the Authorization that are covered by the revocation.

I understand that if I submit a revocation, there may be a delay between the time I submit it and the time the applicable Confidential Information is removed from further disclosure, but this delay will generally not exceed 3 working days.

I understand that Austin HMIS ServicePoint Agencies cannot control how the Confidential Information will be used by the agency/person who receives it under this Authorization, that there is the potential for redisclosure by the recipient and that the disclosed Confidential Information may not be protected by federal privacy regulations.

I understand that I may review and receive a copy of the Confidential Information released pursuant to this Authorization if I request it. I further understand that I may be required to pay a fee for copies of this Confidential Information.

I understand that I may refuse to sign this Authorization and that treatment, payment, or eligibility of benefits will not be conditioned on my signing this Authorization, and that I will receive a copy of the signed Authorization.

I understand that this Authorization expires one (1) year from the date I sign it, unless otherwise revoked by me in writing prior to that time. If I revoke it on behalf of some but not all of the persons listed below, the Authorization will remain in effect as described above with respect to those persons to whom the revocation does not apply.

______Name of Individual

______Name of Child (if applicable)

______Name of additional Child (if applicable)

______Individual/Parent/Guardian Signature Date

______Relationship to each Child(ren) listed above

______Witness Date

Shared by Austin Travis County MHMR, Austin, TX on HMIS.info 3 Universal Consent Form What is ServicePoint? entered into the Austin Area ServicePoint system, which operates over the Internet. ServicePoint uses When you request or receive services from many security protections to ensure agencies participating in the Austin area confidentiality and only agencies ServicePoint Homeless Management that use ServicePoint in Austin can Information System, we collect information access this program. about your household and enter it into a  You can decide what information is computer program that helps us to keep shared with other agencies, and track of that information. This program is which agencies have access to your used by many agencies throughout Austin information. that provide services to homeless and low- income persons.  If you allow us to share information about you, only authorized persons What information is collected about you? at these agencies will have access to Depending on your situation, you may be it. asked for some or all of the following: Why should you agree to have your  Basic identifying information (may information shared with other Austin include name, SSN, date of birth, agencies that use ServicePoint? gender, race, marital and family By sharing your information with these status, household relationships, agencies, you will help them: phone numbers, military veteran status, whether or not you have a  Identify other services or programs you disability) may be eligible for,  Housing information (may include  Better coordinate services for you and address, type of housing, homeless your household, status, reason for homelessness)  More accurately count the number of  Income information (sources and homeless persons, the services available amounts of household income, and what other services are needed, employment information, work Show the people who fund homeless programs that skills) the services are needed and help the agencies to obtain other funding for programs that serve  Legal history/information homeless persons.  Medical information  Services needed and provided; outcomes of services provided

Why is the above information collected?  To better assess your needs and the needs of others in your community, as well as what services are available to you  To track whether your needs, and the needs of others in your community, were actually met  To improve the quality of care and service for homeless individuals and families

What happens to your information?  When you request services from this agency, your information will be Shared by Austin Travis County MHMR, Austin, TX on HMIS.info 4 Universal Consent Form