I understand and acknowledge that this agency is a member of the HUD/Homeless Management Information System, hereafter known as “HUD/HMIS,” and I consent to and authorize the collection of data and information maintained by this agency to “HUD/HMIS” and affiliated agencies, provided such agency is a party to the “HUD/HMIS” agency agreement under which the agency has specifically agreed to share information.
These agencies include, but are not necessarily limited to participants in the “HUD/HMIS” grant, and the United Way Outcome Measures Pilot Project. The data, information and records gathered and prepared by the Agency and “HUD/HMIS” will be included in the database and may be utilized by “HUD/HMIS” and affiliated agencies to: a) provide individual case management; b) produce reports regarding utilization of services; c) track individual program outcomes; d) provide accountability for individuals and entities that provide funds for use in providing services in Brevard County; e) identify unfilled service needs for the provision of new services; f) allocate resources among agencies engaged in the provisions of services in Brevard County and g) be used for all other uses to be determined appropriate by “HUD/HMIS.” I understand and acknowledge that my data and information may be used in aggregate data along with information of other individuals served by the
Agency, will only be disclosed to agencies, individuals and entities other than “HUD/HMIS” only with my written authorization.
I understand and acknowledge the data pertaining to the services provided to me may include
medical/health information- the privacy of which may be protected by Federal or Florida State laws and expressly consent to the release of such information in accordance with these protections.
I understand and acknowledge that I have the right to a) inspect, copy and request amendment of all records maintained by the Agency related to the provisions of services and to receive a paper copy of this form; and b) to file a grievance if I believe my privacy rights have been violated. This grievance must be submitted in writing to the agency’s complaints manager and will be responded to in accordance with the Agency’s Privacy Policies and Procedures.
I understand and acknowledge that I have the right to opt out of having my data, information and records disclosed to “HUD/HMIS” and affiliated agencies by providing notice to the Agency and that I am entitled to services regardless of my decision. I further understand and acknowledge that I may revoke this consent at any time by providing written notice to the Agency.
(Signature of Applicant)
(Printed name of Applicant)