MSHMIS Client Release of Information
Introduction: This form is about the Michigan Statewide Homeless Management Information System. We call this system the MSHMIS. Many shelters and other helping programs use the MSHMIS system. The MSHMIS System keeps information about clients that get help here.
The purpose of this form is to:
· Inform you about Michigan’s record keeping system
· Determine the information to be shared through the MSHMIS Search Screen
· Determine your participation in planned sharing with other Detroit agencies
· Determine your consent for releasing confidential information
· Obtain a end date of the release of information
The information you give may also be used by other helping agencies in the system, but first you must agree to share information, before any sharing can occur. Sharing information will help reduce the paperwork you would have to fill out at other agencies. It will also allow agencies to work together to help you.
The MSHMIS Search Screen
When I sign below, it means:
- I was told about the MSHMIS System and I received a copy of the Privacy Notice. I know there are both benefits and risks when I agree to share my information.
- I know that the only information other agencies can see without my permission are my name, year of birth, gender, veteran status, and the last 4 digits of my Social Security number. My personal information lets other agencies know that I have been helped by an agency in the system. It is used to pull or search for the correct record in the System. It does not identify which agency or what services I received.
- I know that there is a list of all the agencies in the MSHMIS System that I can find on the Internet at www.mihomeless.org. These agencies must follow strict privacy laws. The agencies in the system may change from time to time.
-There may be a reason why sharing my name, year of birth, gender or partial Social Security Number on the open part of the system may put a family member or me at risk. If that is true, I have initialed below which information should NOT be shared.
Name, Year of Birth, Gender, Veteran Status: ______, Partial SS#: ______.
-I know that if I have already received services from an organization using the System and I have left my name visible, I will have to ask that organization to close my “Profile/Name”. The name is usually left visible in our System to allow us to better coordinate services.
Planned Sharing With Other Detroit Agencies
- I agree, by initialing the “Yes” below, that additional information may be shared with other agencies. Below is a description of the information shared and a list of participating agencies. Sharing allows other agencies to do a better job helping my family and me. I know my decision to share or not to share additional information will last until the “End Date” of this release identified on the next page.
Yes: / No:
Description of What Is Shared
The MSHMIS Client Release Form authorizes the following information to be routinely shared using the MSHMIS to better help my family or me.
Evaluation/Assessment Information Related to:Additional Profile (Basic client demographics) / Homeless Information (prior living situation, reason for homelessness, housing status, extent of homelessness)
Children’s school enrollment status / Household Data
Case notes / Income (cash and non-cash)
Client Profile (Client Name, Yr of birth, gender, partial ss#) / Outreach data
Custom Assessments / Referrals
Destination when exiting a project / Services
Disability and Health Information / SPDAT Assessment (Client Wellness, Risks, Socialization, Daily living skills, Physical and mental health and wellness, Relationships, Abuse/trauma, Substance abuse, Homeless/housing history, Money management, Legal and Risks)
Education Data / Veteran Status and Information
Employment Data / Risk factors for homelessness
The information listed above will be shared with the following agencies:
Alternatives for Girls, Black Family Development, BlueWater CIL, Cass Community Social Services, Community Home Supports , Community Social Services, Coalition On Temporary Shelter, Covenant House, Family Service – NOAH, Gateway Detroit East, Detroit Central City Community Mental Health, Development Centers, Detroit Rescue Mission Ministries, EACH, Emmanuel House, Faith Love N Kindness, HAPI Housing Program, Legal Aid and Defender, Love Outreach, Lutheran Social Services, Mariner’s Inn, Matrix Human Services, Michigan Legal Services, Michigan Veterans Foundation, New Day Multi Purpose Center, Neighborhood Legal Services of Michigan, Neighborhood Service Organization, Operation Get Down, Perfecting CDC, Positive Images, Ruth Ellis, Shelters of Love, Southwest Counseling Solutions, St. John’s Community Center, Traveler’s Aid Society, Road Home, The Salvation Army, The Heat and Warmth fund (THAW), United Community Housing Coalition, Volunteers of America, DCH PATH DCH S+C.
Other uses of data:
By signing below, I further understand that the evaluation and assessment data mentioned above will be entered into the Homeless Management Information System (HMIS) and that the assessment data can be entered or transferred into a housing database. The housing database will be used to match my assessment data against eligibility requirements of housing that becomes available and any other services that I may be eligible for. Both the HMIS and housing databases are HIPAA compliant and follow HIPAA guidelines. Participating does not guarantee that I will be contacted for a housing opportunity. I further understand that my name may be provided to non-participating organizations that are not listed above such as soup kitchens, churches, etc., in an effort to locate me for housing opportunities that may become available. These agencies include, Capuchin Soup Kitchen, Kelly’s Shelter, and other Soup Kitchens and Churches where clients frequent.
Consent for Release of Confidential Information
The purpose of the disclosure authorized in this consent is to:
Help ensure that I and my family receive the best care possible from participating agencies.
o I understand that my treatment records are protected under state and federal regulations governing confidentiality of patient records.
o The regulations are the Federal Law of Confidentiality for Alcohol and Drug Abuse Patients, (42 CFR, Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 CRF, Parts 160 & 164.
o The records cannot be shared without my written consent except as provided for in the regulations.
o I also understand that I may end this consent.
o I understand that there may have been information shared and services provided based on this consent when it was in effect. Ending this consent cannot change that.
o I understand that any notice to end this consent must be in writing.
o This consent will automatically expire .(date)
I understand that generally (agency) may not condition my treatment on whether I sign a consent form. However, if collaboration between agencies is a requirement of program design, I may be denied treatment if I do not sign a consent form.
Client signature: ______, Date: ______,
Parent, Guardian or Authorized Representative signature: ______
Relationship to client: ______
Release End Date: The release will apply until: ______
2 / HMIS Release of Information 1/16/15