Client Release of Information: HMIS

This agency participates in the Homeless Management Information System (HMIS) by collecting information, over time, about the characteristics and service needs of men, women, and children experiencing homelessness.

To provide the most effective services in moving people from homelessness to permanent housing, we need an accurate count of all people experiencing homelessness in the region. In order to make sure that clients are not counted twice if services are received by more than one agency, we need to collect some personal information.

*What information is collected about you? You may be asked for the following:

• Personal Identifying Information (Such as name, social security number, date of birth, and contact information such as address and phone numbers),

• Demographic information (Gender, race, ethnicity, etc.),

• Household information (family members, marital status, the type of housing you live in or homelessness status, domestic violence history, reasons for homelessness, etc.)

• Information related to your employment or ability to work (Household income, work skills, military veteran status, disability status, substance abuse issues or pregnancy status, etc.)

• Services needed and provided, and

• Outcomes of services provided.

This information is used to improve the quality of service you, and others like you, receive. You have the right to refuse to provide this information. Your information will be stored in our database for 7 years.

• We will guard this information with strict security policies to protect your privacy. Our computer system is highly secure and uses up-­‐to-­‐date protection features such as data encryption, passwords, and identity checks required for each system user. There is a small risk of a security breach, and someone might obtain and use your information inappropriately. If you ever suspect the data in HMIS has been misused, immediately contact System Administrator, TVCEH, at 865-­‐210-­‐1200.

• It is possible that information from HMIS could be subpoenaed by the court system for legal use. Active members of law enforcement as well as detention and corrections staff are not authorized access to HMIS. It is possible that very limited exceptions may be negotiated in the future, such as in the case that a prisoner reintegration program is implemented, or in a similar circumstance.

• If you are fleeing domestic violence, please consider that your information is viewable by authorized members of other agencies currently using HMIS. It may be more appropriate for you to request services from an agency specializing in domestic violence. Domestic violence providers are barred by law from entering information into HMIS.

• Your decision to participate in HMIS will not affect the quality or quantity of services you are eligible to receive from this agency, and will not be used to deny outreach, shelter or housing. However, if you do choose to participate, services in the region may improve if we have accurate information about homeless individuals and the services they need.

• You may request a comprehensive list of agencies that have access to your information via written or verbal request to the agency that collected your information. I DO consent to the inclusion of personal information in HMIS about me, and any dependents listed below and authorize information to be collected and shared with current HMIS participating agencies.*

*A complete list of agencies can be supplied as requested.

I understand that my personal information will not be made public and will only be used with strict confidentiality. I also understand that I may withdraw my consent at any time.
  • Dependent Children Under 18 in Household:

  • Client Release of Information

    By entering your name and date below, you are consenting to the release of your information.
  • If you DO NOT Consent to Information Release

    By entering your name and date below you stating that you DO NOT consent to my information being shared with outside agencies. I recognize that my information will still be viewable by the HMIS Administrator.