GA HMIS Release

  • Georgia Homeless Management Information System (GA HMIS) Collaborative Client Consent to Share Information

    The Georgia Homeless Management Information System (“GA HMIS”) is an online database that is used to collect information (data) about clients accessing housing and homeless services throughout the State of Georgia. Organizations that receive homeless funding from the US Department of Housing and Urban Development (HUD) and other federal and state partners are required to collect and store basic information about the persons who receive their services. This organization participates in the GA HMIS and by requesting and accepting services from them you are providing consent to enter your personal information into the GA HMIS. This information is utilized to determine your needs and provide supportive services to you and your household, and information is shared with other organizations that use this database, based on your signed consent.

    What type of information may be shared in the HMIS?

    We collect general and Protected Personal Information about you and record it in GA HMIS. The information shared through HMIS is dependent on your situation, and may include, but is not limited to:

    • Your basic identifying information (including name, Social Security Number, date of birth, gender, race/ ethnicity, marital and family status, household relationships, contact information, veteran status, disability status);
    • Your history of homelessness and housing (including your current housing status, present and/ or prior living situation, and where and when you have accessed services);
    • Your income information (sources and amounts of household income, employment information, work skills) andother resources, such as non-cash or public benefits;
    • Your legal history/information;
    • Your general, self-reported medical history including any mental health and substance abuse issues or HIV status (detailed medical or treatment information will never be shared, however), and type of health insurance;
    • Your reasons for seeking services, your service needs, and the outcomes of services provided to you;
    • Your emergency contact information;
    • Other information needed for eligibility of certain types of projects (such as military history, educational background, employment background, sexual orientation, etc.)

    How do you benefit from sharing your information?

    The information you provide to GA HMIS helps us coordinate the most effective services for you and/or your family. By sharing your information, you may be able to avoid being screened more than once, get faster and more personalized services, and minimize how many times you have to tell your “story.” Collecting this information also gives us a better understanding of homelessness in your local area and the effectiveness of the services provided in your area.

    Who may be given access to your information?

    The GA HMIS participating organizations may have access to your data on a need-to-know basis. These organizations may include homeless service providers, other social services organizations, housing providers, healthcare providers and administrators of the system. In other rare cases, such as when required by law, or for purposes of research, your information may be shared outside of the GA HMIS participating organizations (but never to the general public). For more information, please request a copy of our privacy policy.

    How is your personal information protected?

    Your information in the HMIS is secured by passwords and encrypted transmission technology. In addition, each participating organization and system user must sign an agreement to maintain the security and confidentiality of the information. Your information is protected by the federal HMIS Privacy Standards. In some instances, depending on the services provided by a participating organization, your information may also be protected by additional Federal and/or State regulations, which may require additional written consent prior to any disclosure.

    By signing this form, you understand that:

    • You have the right to receive services even if you do not agree to share your information.
    • Consenting to share your information does not automatically guarantee you services.
    • You have the right to receive a copy of this consent form.
    • Your consent allows your record to be updated by any participating organization with which you interact without you being required to sign another consent form.
    • Your consent does not expire, but you may cancel your consent at any time, by completing the Client Revocation of Consent to Share Information form. You further understand that any cancellation of this consent will not retroactively change information that has already been disclosed or actions already taken under your previous authorization.
    • The GA HMIS Privacy Policy contains more detailed information about how your information may be used and disclosed.
    • Upon your request, we are required to provide you with, as applicable:
      • A copy of the Client Revocation of Consent to Release Information;
      • A copy of the GA HMIS Privacy Policy;
      • A copy of your full HMIS records (apart from case notes) within five (5) business days of your request;
      • A current list of participating organizations that have access to your data.
    • If you find inaccurate or incomplete Protected Personal Information in your records, you have the right to request a correction.
    • Aggregate or statistical data that is released from HMIS will not disclose any of your Protected Personal Information.
    • You have the right to file a grievance against any organization you feel has violated your confidentiality.
    • If you need to be referred to another agency for services, certain information may need to be forwarded through HMIS to facilitate a referral. If you do not provide consent to share your information, it may negatively affect participating providers from addressing your service needs in a coordinated fashion.
    • You are not waiving any rights protected under Federal and/or Georgia law.
  • Your signature below indicates that you have read (or have been read) this client consent form and have received answers to your questions. Please indicate your sharing preference by choosing one of the options below:
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  • Minor Children (if any):
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