February 4, 2012

HMIS Agency Agreements and Client Consent Forms

The Homeless Missourians Information System (HMIS) Steering Committee has developed a set of operating forms for your agency’s use with the 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 title of the form. These forms can also be obtained from MASW by contacting via email Liz Gebhart, HMIS Project Coordintator (Regions 1, 6, 7, 8 & 9) or Lindsay Wallace, HMIS Project Coordinator (Regions 2, 3, 4, 5 & 10) or by calling 573-632-2567.

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 (Revised June 2011)

This form is an agreement between your agency and the Missouri Association for Social Welfare (MASW), the agency that received the grant from HUD to administer the HMIS. 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.

Procedure: The Executive Director of your agency, or a person with similar responsibility, should read and sign this form. The original form must be signed in blue ink and returned to MASW before your agency will be granted access to the HMIS database. The agency should keep a copy for their files. The form must be mailed to MASW, Attention: HMIS Project, 606 East Capitol Avenue, Jefferson City, MO 65101.

User Policy and Responsibilities (Revised June 2011)

Individuals working on behalf of an agency (employee, contractor or volunteer) that will be accessing HMIS must be designated as an HMIS User. HMIS Users are designated by the Partner Agency's Executive Director or authorized representative.

Procedure: The Partner Agency’s Executive Director or authorized representative will obtain the HMIS User Policy and Responsibilities Form which must be signed in blue ink by the designated HMIS User and the Partner Agency’s Executive Director or authorized representative. The original form must be mailed to the HMIS Project Coordinator at the following address in order for the designated HMIS User to be registered for HMIS training: Missouri Association for Social Welfare, Attn: HMIS Project, 606 E. Capitol Ave., Jefferson City, MO 65101

Privacy and Security Notice (Revised June 2011)

This notice describes the HMIS privacy policy of your agency. The information collected by your agency includes: basic identifying demographic data, such as name, address, phone number and birth date; the nature of the clients situations and the services and referral they receive from your agency. This information is known as the clients Protected Personal Information or PPI. All agencies which utilize the HMIS share their data with other participating agencies, with the exception of Blind Services Providers. Blind agencies service specific protected client populations, such as HIV/AIDS, alcohol and/or substance abuse, and mental health, and do not share client information. All clients served by your agency is covered by this policy.

Procedure: This document will need to be edited on page three and page four. Make sure that you edit the “Header” and add your agency name. When completed return a copy of the HMIS Data Privacy Policy to the HMIS Project office via email and then place a copy into your HMIS Policies and Procedures binder or file. All Agencies must provide a copy of the Privacy and Security Notice with the client should they request one.

Notice of Client Rights (Revised June 2011)

By signing the Notice of Client Rights form, the client understands that any information s/he shares with an agency participating in HMIS is kept confidential and that only those authorized to input data into HMIS can view their personally identifying information; all health information, however, will not be shared. By signing this form, the client also understands s/he has the right to refuse to answer a certain question in HMIS and, furthermore, that if s/he decides at a later date they no longer want their information to be in HMIS, that s/he can request it be removed.

Procedure: Obtain a signed Notice of Client Rights form from every client who will be entered into HMIS. Maintain the original, signed Notice of Client Rights form in client’s hard copy file. Agency will continue to maintain the original, signed Notice of Client Rights form for each client entered into HMIS for a minimum of three years from client’s program exit date.

HMIS Consumer Notices

The HMIS Project Consumer Notice explains to the client the Partner Agency participates in the HMIS Project.

Procedure: This notice must be placed in a visible area where clients will have the opportunity to view it. A list of the HMIS Partner Agencies who participate in HMIS can be obtained on the MASW website at: http://www.masw.org/HMIS/documents/HMISPartnerAgenciesMay2011.pdff.

HMIS Technology Equipment Reuse and Disposal Policy

Any computer, printers, copiers and fax machines that will no longer be used to access HMIS will have its hard drives reformatted multiple times before being used again by the Partner Agency or anyone else. A computer that is being disposed of will have its hard drives permanently destroyed and disposed of in a secure manner.

Procedure: The agency will modify the form to reflect the agency’s information per the instructions. Once completed the original form will be mailed to HMIS office with a copy maintained at the agency’s office. Mail to: Missouri Association for Social Welfare, Attn.: HMIS Project, 606 East Capitol Avenue, Jefferson City, MO 65101. New User Enrollment Process

Receipt of ROSIE Manual

The purpose of this form is to acknowledge receipt of the ROSIE manual CD.

Procedure: It is the responsibility of the Agency Representative to fill out the form as indicated. When completed the original form will need to be mailed to the HMIS office at: Missouri Association for Social Welfare, Attn: HMIS Project, 606 E. Capitol Ave., Jefferson City, MO 65101. Agency should keep a copy for their files.

Helpful Tools

HUD's Newest Technical Data Standards - March 2010

Updated: 11/20/2008