Consent Form - NESFNJ

To apply for NESF services, please complete the below consent form

NJHMIS Collaborative Consent — Release of Information for Data Sharing via NJHMIS

The NJHMIS Collaborative Homeless Management Information System (HMIS) serves the New Jersey Continuums of Care communities and State agencies which include partner agencies working together to provide services to individuals and families in New Jersey who are homeless or at risk of becoming homeless. Information collected in the HMIS database is protected in compliance with the standards set forth in the Health Insurance Portability and Accountability Act (HIPAA) and the U.S. Department of Housing and Urban Development HMIS Data Standards. Every person and agency that is authorized to read or enter information into the database has signed an agreement to maintain the security and confidentiality of the information. Any person or agency that is found to violate their agreement may have their access rights terminated and may be subject to further penalties.

• I UNDERSTAND THAT: The partner agencies may share limited identifying information about the people they serve with other parties working to end homelessness.

• The release of my information does not guarantee that I will receive assistance.

This release of information includes public funded cash disbursements received during the past 3 years.

• This authorization will remain in effect for a minimum of months unless I revoke it in writing, and I may revoke authorization at any time by signing a written statement or Revocation form.

• The following personal information will not be shared with any NJHMIS partner agencies via the NJHMIS computer system..

1. HIV/AIDS information, such as status, diagnostic test results, mode of transmission, sexuality
2. Domestic violence information, such as abuse history, abuser information, trauma information.
3. Behavioral health information, such as substance and alcohol abuse and mental illness.
4. Clients supportive services contacts, medication information and case notes.

• If I revoke my authorization, all information about me already in the database will remain, but will become invisible to all of the partner agencies, except public (county, state or federal) cash disbursements.

If I am applying for county, state or federal cash disbursements such as SSH, HPRP, and TANF Emergency Assistance, this information will be shared with NJHMIS Collaborative users and State agencies.
By signing this form, I agree to share the following level of information with other NJHMIS partner agencies via the NJHMIS computer system:

By signing this, form, i agree to share the following level of information with other HJHMIS partner agencies vi the HJHMIS computer System

A) I agree to share my [Name(First, Middle, Last), client gender, ancestry, program enrollment and exit dates, demographic information, miscellaneous information, contacts information, cash disbursements information via the HMIS System with other NJHMIS Partner agencies.

B) i do not agree to share any of my information via the HMIS SYSTEM WITH OTHER his Partener agencies via the HMIS system with other HJHMIS Partner agencies.

Client Name

Client Name (please print) Client Signature

Date

Guardian Name

Guardian Name, if required (please print) Guardian Signature

Date

Consent*

I agree to the privacy policy.

Adults

Email*

Number of Adults*

Please enter a number greater than or equal to 1.

Names*

Children

Number of Children

Please enter a number greater than or equal to 0.

Names

Comments

This field is for validation purposes and should be left unchanged.