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.