Full Text
Minnesota’s HMIS 9-27-11 Instructions PLEASE READ BEFORE USING CONSENT FORMS **THIS PAGE NOT MEANT FOR DISTRIBUTION TO CLIENTS** These forms were developed based on federal rules governing Homeless Management Information Systems (Federal Register, Vol. 69, No. 146, July 30, 2004), and additional guidance from Minnesota’s HMIS Governing Group. How to use the HMIS consent forms and notices 1. Minnesota’s HMIS: Data Privacy Notice & Consent Form should be given to all adult clients or single unaccompanied youth. Parents can give consent for their children. Clients who do not sign the form should be entered only using ServicePoint’s “Enter as Anonymous” feature. Drop-in shelters, street outreach programs, and telephone-only services may substitute a brief verbal notice and consent for use of this form. 2. Minnesota’s HMIS: Release of Information is only for agencies that would like to provide their clients with the option of sharing data with other service-providing agencies that use Minnesota’s HMIS. This page is not necessary for DV agencies, Youth agencies, HIV/AIDS agencies, HIPAA-covered agencies, and others that do not intend to share data. If using the form, please be sure to include a list of up to ten agencies with whom you would like to share data in the space provided, and communicate these “closed exemption” agencies to Wilder Research ([EMAIL REDACTED]). Note that we are not allowing a share with all ServicePoint agencies option. 3. Minnesota’s HMIS: Posted Data Privacy Notice is not intended for distribution to clients. Please post this sign in an area viewable by clients. Note that throughout the forms the phrase “this agency” can be replaced with the actual name of your agency. This document can be further modified and/or incorporated into an agency’s existing data privacy forms and notices, but modifications should only be made in consultation with legal counsel. Also note that these forms apply only to data maintained in Minnesota’s HMIS. They are NOT meant to serve as an agency’s complete privacy policy or sole consent forms. The following situations, for example, require some additional privacy-related provisions for your clients: Agencies covered by Minnesota’s Government Data Practices Act, need to provide clients with a Tennessen warning that lists the specific governmental agencies that fund the programs and, therefore, may view client data Minnesota Department of Human Services, Minnesota Housing Finance Agency, U.S. Department of Housing and Urban Development). Consult your funder and see the Minnesota Department of Administration’s Information Policy Analysis Division (http://www.ipad.state.mn.us/ ) for further information. HIPAA covered agencies: The federal government’s “Health Insurance Portability and Accountability Act” (for more info, see http://www.hhs.gov/ocr/hipaa/ ) supersedes federal HMIS regulations. By law, these agencies are not required to provide clients with “Minnesota’s HMIS: Data Privacy Notice & Consent Form,” but they are encouraged to do so, since the form provides information about the system. In addition, HIPAA covered agencies need to provide clients with an opportunity to opt-out of including their data in research. A check-box such as the following should be added somewhere to either the HMIS Notice & Consent forms, or the agency’s forms: Consent for research uses of information in Minnesota’s HMIS. Please check one: Yes, include in research. I understand that information about me that is in Minnesota’s HMIS may be used by Wilder Research to conduct research related to homelessness and housing programs, service needs, income supports, education and employment, and program effectiveness. My name, social security number or other information that would identify me personally will never appear on a research report. No, do not include in research. I do not want my information used for research purposes. HUD-Funded agencies need to explicitly list HUD as having rights to view client data entered into Minnesota’s HMIS. Please replace the second bullet under “who can see information entered into HMIS?” (currently “Auditors or others who have legal rights to review the work of this agency”) with, “Auditors or others who have legal rights to review the work of this agency, including the U.S. Department of Housing and Urban Development.” ---PAGE BREAK--- Minnesota’s HMIS Client Notice & Consent 9-27-11 Minnesota’s HMIS Data Privacy Notice & Consent We collect personal information about the people we serve in a computer system called Minnesota’s HMIS (Homeless Management Information System). Many social service agencies use this computer system. Why? To help keep this program and others like it going. We are required to use HMIS. So we know how many people we serve and the types of people we serve at our agency and in the state. So we all understand what people need and can plan services to meet these needs. Who can see information that is in Minnesota’s HMIS? People who work for this agency will use it to help provide services to you or your family. Auditors or others who have legal rights to review the work of this agency, including the U.S. Department of Housing and Urban Development Some people who work for Wilder Research (in St. Paul). Wilder runs Minnesota’s HMIS. When Wilder works on the system, they may see information about you. People using HMIS information to write reports. Researchers must sign an agreement to protect your privacy before seeing HMIS information. Your private information will never appear in research reports. The law says we have to report physical or sexual abuse of children and vulnerable adults. If we think there is abuse or neglect in your household, we will report it to Child or Adult Protection. We may release your information to protect the health or safety of you or others. Others when we are required by law, including officials with a valid subpoena, warrant, or court order. We will not release your data for any other use unless you permit us, in writing. Your Rights If you do not want your name, social security number, or date of birth entered in HMIS, tell the intake worker. This agency will not refuse to help you for denying this. You have the right to a copy of the Minnesota’s HMIS information about you. (Unless we cannot give it because of certain legal proceedings.) You have the right to correct mistakes in HMIS information about you. If you think this agency or Minnesota’s HMIS violated your privacy rights, you have the right to complain or appeal. Ask a staff person for a complaint and appeal form. Or, write to Minnesota Coalition for the Homeless, HMIS Grievance, 2233 University Avenue West #434, St. Paul, MN 55114. Signed Consent Each adult and unaccompanied youth must sign for him or herself. A parent/guardian should sign for children under 18. For: Print First and Last Name – use back of page for children’s names & birth dates Date of birth My signature shows that I permit you to enter my personal information into Minnesota’s HMIS. (You do not have to sign this form to receive services from this agency.) SIGNATURE OF CLIENT OR GUARDIAN DATE Signature of witness Date ---PAGE BREAK--- Minnesota’s HMIS Client Release of Information 9-27-11 Minnesota’s HMIS Release of Information For: Print First, Middle, and Last Name Date of Birth If you permit it, this agency may share your HMIS information with the agencies listed below. Together, we may be able to serve you better. Please check a box: DO NOT SHARE: I do not want any of the information about me in Minnesota’s HMIS shared with any other service providers. (Data security = Closed) SHARE: This agency may share my name, date of birth, race, ethnicity, Social Security Number, and the same information from any other members of my family who are being served with me at this time. (Data security = Closed with exceptions) Make a check mark beside agencies we can share with. Minnesota Department of Human Services Minnesota Housing Finance Agency U.S. Department of Housing and Urban Development Which information can we share with the agencies checked above? (Open padlocks on selected items) Services you receive Educational background Your income and income sources Employment status If you are homeless or not Military history Reasons for seeking services Other: Living situation and housing history Other: When you sign this form, it shows that you understand the following. We will not deny you help if you do not want us to share your personal information. If you permit us to share your data, this consent will expire in one year. If you permit us to share your data, you may change your mind and cancel this consent at any time. The people listed on Minnesota's HMIS Data Privacy Notice, and this agency's privacy notice, may see your information in HMIS. They may see it even if you tell us we cannot share. SIGNATURE OF CLIENT OR GUARDIAN DATE Signature of agency witness Date Please treat information about my children age 17 or younger the same as mine. ---PAGE BREAK--- Minnesota’s HMIS Posted Notice 9-27-11 Minnesota’s HMIS Posted Data Privacy Notice We collect personal information about the people we serve in a computer system called Minnesota’s HMIS (Homeless Management Information System). Many social service agencies use this computer system. We use the personal information to run our programs and to help us improve services. Also, we are required to collect some personal information by organizations that fund our program. You do not have to give us information. However, without your information we may not be able to help you. Also, we may not be able to get help for you from other agencies. You have a right to review the personal information that we have about you. If you find mistakes, you can ask us to correct them. You have a right to file a complaint if you feel that your data privacy rights have been violated. Please tell our staff if you have questions. If you need a grievance form or a complete copy of our privacy policy, please ask our agency staff.