AUTHORIZATION TO RELEASE/SHARE INFORMATION
· RELEASE A – HMIS: Client should sign Release A to get service, but cannot be denied service if refusing to sign.
· RELEASE B - HOUSING SEARCH: Client may choose to sign if s/he wishes assistance in housing search.
RELEASE A. I ______(sign your name here) hereby authorize the release of anonymous information to HUD taken from my case record for the sole purpose of running reports on the degree of homelessness in this area of the country.
Your signature on the line above gives permission for anonymous HMIS reporting, and for nothing else. Date I signed this: ______/______/______
RELEASE B. I ______(sign your name here) hereby authorize the entry of basic housing application information to HousingWorks, Inc.; and to and from all relevant housing agencies, for the purpose of getting me into stable or permanent housing.
Your signature on the line above gives permission to the advocate to use HousingWorks as a search, apply, and/or waitlist maintenance service for you.)
Date I signed this: ______/______/______
I also understand:
1. Signing the HMIS Release (A, above) gives your advocate permission to send anonymous information about homelessness to HUD;
2. Signing the HousingWorks Release (B, above) is a second, optional release. Here’s how you benefit if you choose to sign this second release: HousingWorks will help you apply to more permanent housing more quickly. The information we want permission to store is restricted to answers to questions found on every housing application: name, family size, income, housing history, etc. With your signature, your advocate can use HousingWorks to send more applications, and update your waitlists with your changing circumstances (for instance, if your address changes and you still want to be reachable when someone has an apartment for you.). Here’s why it is safe to use HousingWorks: Using HousingWorks, no landlord or housing authority will learn anything about you that you have not provided them with on your application.
3. I can revoke my advocate’s access to my information at any time, just by visiting another advocate who is using the HousingWorks system and changing my secret password. This access is subject to my revocation at any time, except for information already released;
4. This authorization covers both the release of that information specified above and information to be compiled during the course of client’s involvement with this agency;
5. I understand that I have a right to receive a copy of this authorization;
6. I understand that by signing this release I authorize this agency's auditors to view information contained in my file (for audit purposes only);
7. A copy or xerox of this page is as valid as the original. You should have a copy and your advocate should have a copy.
RELEASE FORM FOR HOUSING SEARCH
My signature below acknowledges my understanding and authorization and consent for the following:
1. This Authorization for Release of Information is valid until it is revoked in writing by the applicant;
2. This authorization is subject to my revocation at any time, except for information already released;
3. This authorization covers both the release of that information specified in the section Restrictions on the Use of Information and also the information to be compiled during the course of client’s involvement with the agency or program;
4. I understand that I have a right to receive a copy of this authorization form, including the REVOCATION OF AUTHORIZATION form below;
5. I understand that by signing this release I authorize this agency's auditors and HousingWorks tech support staff to view information contained in my file (for audit purposes only);
6. A copy of this form is as valid as the original;
7. My advocate cannot withdraw any of my applications without reasonable attempts to contact me. My agency will discuss with me the greatest length of time I can choose not to respond to attempts to contact me before any applications are withdrawn. It is my responsibility to stay in touch with the agency unless I revoke their authorization using the agency’s form or the form below. (Be sure to sign on next page)
______Date: ____/____/______
Name of Client/Parent/Guardian Relationship to Client Witness to Signatures
How client was informed of the above information:
_____ Client read and signed this form
_____ Verbal explanation of this form was provided point by point by advocate
_____ An interpreter was provided
______Date: ____/____/____
Printed Name of the Housing Advocate I am authorizing Signature of the Housing Advocate I am authorizing
OPTIONAL: Authorization for Use of Signature
Let this serve to verify that I, ______have authorized my housing advocate, ______to sign as my agent on housing applications submitted on my behalf, including but not limited to, releases of information, fair housing practice forms, and requests for criminal history forms. Further, any questions regarding my housing needs may be addressed directly to my housing advocate. This form is good until I revoke the advocate’s authorization by signing the Revocation on the next page, or by visiting another housing advocate to whom I can give the ability to block any of my other advocates from sending future applications.
______Date: ____/____/______Date: ____/____/____
Applicant’s Signature Housing Advocate
REVOCATION OF AUTHORIZATION
Do not sign this section unless you wish the advocate to stop working on your behalf
WRITTEN REVOCATION: I hereby revoke all authorization for the releases specified on this page.
______Date: ____/____/____
Signature of Client/Parent/Guardian
ORAL REVOCATION: Client/Parent/Guardian revoked all authorizations for the above specified client.
______Date: ____/____/____
Signature of Advocate
WHAT AUTHORIZATION(S) ARE REVOKED? c Ability to sign applications c Permission to advocate for me in any way.