Client Release of Information for the Whatcom Housing Group

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Toolkits | March 21, 2012

Files: Whatcom County Release of Information Form | PDF | 1 page

This is an excerpt from the client release of information form. To download the entire form, please use the link above.

As a member of the Whatcom Housing Group, _________________________________ (agency name) has agreed to mutually share information with other Whatcom Housing Group agencies about individuals and families that seek housing services in Whatcom County. This information will be shared through the Homeless Management Information System (HMIS) in order to coordinate and improve programs and services.

To make sure that you are not counted twice, we need your name, birth date, gender, race and last permanent address. Only non-identifying information will be entered for clients currently fleeing or in danger from a domestic violence, dating violence, sexual assault or stalking situation.

HMIS data will also be shared with the Washington State Department of Commerce and combined with data from the Department of Social and Health Services (DSHS) for the purpose of further analysis. Your name and other identifying information will NOT be included in ANY reports or publication. The information will be stored for seven years./

All participating agencies in the Whatcom Housing Group will guard this information with strict security policies to protect your privacy. The HMIS software is highly secure and uses up-to-date protection features such as data encryption, passwords, and identity checks required for each system user. There are no reasonably foreseeable risks associated with participation in the HMIS system. However, if you ever suspect the data in the HMIS has been misused, immediately contact the HMIS System Administrator at (360) 725-3028.

Your decision to participate in HMIS will not affect the services you are able to receive from this agency or other agencies in the Whatcom Housing Group. However, if you do choose to participate, the information you provide may be used to improve services in our community.

Additional agencies may join the Whatcom Housing Group and will have access to your information based on this authorization. Upon request, you are entitled to a copy of a list of current Whatcom Housing Group agencies before signing the release and anytime thereafter. You may withdraw your consent at anytime.