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HMIS Agency Agreements and Client Consent Forms

The West Central Illinois Continuum of Care Consortium (WCICCC) Steering Committee has developed a set operating forms for your agency’s use with the Homeless Management Information System (HMIS) database. The forms are required to be used by all participating agencies, and are described below (Adobe® Acrobat Reader® is required... click here to get the FREE Adobe® Acrobat Reader®). To see and print each form, click on the button.

These forms are updated periodically. If you are a participating partner agency, your agency will be notified by email when an updated version of any form is available.

Agency Partner Agreement

December 12, 2014

This form is an agreement between your agency and the WCICCC. Lori Sutton of the Illinois Institute for Rural Affairs at Western Illinois University acts as the HMIS Program/System Administrator on behalf of WCICCC. The form describes our mutual responsibilities in connection with the use of the HMIS database. It spells out many of the duties of the partner agency as a whole toward maintaining the confidentiality of client information. The Executive Director of your agency, or a person with similar responsibility, should read and sign this form. The form must be returned to WCICCC before your agency will be granted access to the HMIS database. You may mail the form to Lori Sutton, Illinois Institute for Rural Affairs, Western Illinois University, 511 Stipes Hall, Macomb IL, 61455.

Client Consent/Release of Information

August 20, 2004

Every client your agency serves must read, understand, and sign this form before your agency may enter his or her information in the HMIS database. The purpose of the form is to ensure that all clients understand why they are being asked for the information collected in HMIS, and what it will be used for. When you serve multiple clients within the same family or household, the head of the household signs and gives consent on behalf of the other members of that household. Please photocopy this form and keep a supply on hand.

Client Revocation of Consent to Release Information

January 17, 2014

Should a client wish to revoke his or her consent to share their information in the HMIS database, the Client must sign this form. The agency staff person assisting the client must also sign the form and immediately notify the HMIS System Administrator. Revocation means that the Client?s information is rendered invisible to all users in the database; the information remains for purposes of aggregate reporting only. You may either mail the form to Lori Sutton, Illinois Institute for Rural Affairs, Western Illinois University, 511 Stipes Hall, Macomb, IL 61455, or fax it to (309) 298-2142.

HMIS Data Standards Manual

May 1, 2014

This Manual is intended to serve as a reference and provide basic guidance on HMIS data elements for CoC?s, HMIS Lead Agencies, HMIS System Administrators and users.

HMIS Policies and Procedures

March 13, 2014

WCICCC's draft HMIS policies and procedures document.

HMIS Privacy and Security Standards

July 30, 2009

The privacy and security standards, as described in the 2004 Data and Technical Standards Notice, seek to protect the confidentiality of personal information while allowing for reasonable, responsible, and limited uses and disclosures of data. These privacy and security standards are based on principles of fair information practices and on security standards recognized by the information privacy and technology communities. The standards were developed after careful review of the Health Insurance Portability and Accountability Act (HIPAA) standards for securing and protecting patient information. Communities are expected to continue to use the 2004 Notice to implement their HMIS. (See page 45927, section 4 for HMIS Privacy and Security Standards)

List of HMIS Partner Agencies

December 12, 2014

The Client Consent?Release of Information form notifies all clients that they have the right to review a list of all the partner agencies that participate in the HMIS prior to signing the Client Consent form. If a client asks to see the list of partner agencies, you may click the above link and display this information to the client, or print out a list and give it to the client. This list is subject to frequent updates, so be sure to check this site for the latest list available.

Sign for Intake Area 11″ x 17″

August 20, 2004

A sign must be posted at each intake desk (or comparable location) that explains, to Clients, the reasons for collecting information for the HMIS.

User Policy, Responsibility Statement and Code of Ethics

December 12, 2014

Each person that your agency wishes to designate as a User of the HMIS database must fill this form out and sign it. The form describes the duties of HMIS users in keeping client information confidential and maintaining the security of the HMIS database. The form(s) must be returned to WCICCC before your agency will be granted access to the HMIS database. You may mail the form to Lori Sutton, Illinois Institute for Rural Affairs, Western Illinois University, 511 Stipes Hall, Macomb, IL 61455