San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information
To Receive Coordinated Care, Referrals and Services,
Please Review and Sign this Authorization Form.
ABOUT RTFH HMIS AND 2-1-1 San Diego CIE: The San Diego County Homeless Management Information System (HMIS) managed by Regional Task Force on the Homeless (RTFH) and the Community Information Exchange (CIE) managed by 2-1-1 San Diego are two separate databases that are used to provide referral services to social services agencies for individuals with healthcare, housing, food, transportation, financial, and other needs. This authorization will allow HMIS and 2-1-1 participating agencies to collect information from you and your care team to assess your needs and put you in touch with social services agencies (Participating Agencies) they work with. Information will be shared with those Participating Agencies that provide services that can address your needs to coordinate referrals and services, track your progress and evaluate our success, among other things.
We are committed to protect your information from unlawful disclosure. This Authorization permits a Participating Agency to re-disclose health information to another Participating Agency and the information may no longer be protected under applicable health privacy laws. However, even if the Participating Agency is not subject to health privacy laws, RTFH, 2-1-1 San Diego, and their Participating Agencies are still required to employ administrative, technical, and physical safeguards to protect all information collected under this Authorization and use and disclose information in accordance with federal and state law.
By signing this form I authorize and request the Regional Task Force on the Homeless (RTFH), 2-1-1 San Diego, and Participating Agencies that they may refer me to or who may already be providing me with services to collect, record, use, and share my personally identifiable health, financial, housing, employment, and other relevant information with each other in order to assess my healthcare, housing, financial, and other needs, and to coordinate my care and provide comprehensive services to me. The types of information that may be collected, used, and shared pursuant to this authorization includes, without limitation, the following to be shared in both HMIS and CIE:
Identifying Information: Name, age, date of birth, social security number,
address, personal ID, race, ethnicity, gender, contact information and contact
information for family members, spouse, and my personal representatives
San Diego County CoC HMIS and 2-1-1 San Diego CIE Multiparty Authorization to Disclose Information.
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Updated March 31, 2020
San Diego County CoC Homeless Management Information System (HMIS)
Multiparty Authorization to Use and/or Disclose Information
- Housing: Current location, destination, period of homelessness, prior residence and local assessment data related to housing
- Financial: Employer, employment status, income, and non-cash benefits
- Military: Veteran status
- Health Information: Health and disability conditions and health insurance
- Sensitive Information: Drug, alcohol, and substance abuse, AIDS and HIV status, disabling conditions, developmental disabilities, mental health, and domestic violence information
Right to Decline or Revoke: I understand that I have the right to decline to share data or to revoke previous Authorization to share at any time by completing the Decline/Revocation form found at https://www.rtfhsd.org/what-we-do/homeless management-information-system-hmis/ and sending it to RTFH at: [email protected] or by mailing it to the Regional Task Force on the Homeless, 4699 Murphy Canyon Road, Suite 104, San Diego, CA 92123.
I also understand that I have the right to individually revoke my consent to share data within 2-1-1 San Diego CIE at any time by visiting https://ciesandiego.org/revoke/
Expiration/Renewal: Unless otherwise revoked, to the fullest extent allowed by law, this Authorization shall remain valid for seven (7) years from the Effective Date indicated below. This Authorization may be renewed with my written consent.
Other Rights: I understand that authorizing the disclosure of information is voluntary and I can refuse to sign. I do not need to sign this form to be assured of housing and/or health care treatment services or enrollment in a housing program or health plan. However, if this Authorization is required for RTFH, 2-1-1 San Diego, and the Participating Providers to provide coordinated referrals and services a nd if I do not sign this Authorization, then my receipt of housing or other services may be limited or delay
Right to a Copy of My Information: I understand that I may inspect or obtain a copy of the information to be used or disclosed from my providers.
Right to a Copy of this Authorization: I have right to receive a copy this Authorization.
Authorized Participating Agencies: The current list of Participating Agencies with whom RTFH and 2-1-1- San Diego may share my information will be posted on the RTFH website: https://www.rtfhsd.org/what-we do/homeless-management-information-system-hmis/ and on the 2-1-1 San Diego CIE website: https://ciesandiego.org/partners/.
Grievance Procedure for Clients
1. Purpose and Client Rights
Doors of Change is committed to respectful, trauma-informed, and responsive services. This procedure explains how clients can ask questions, raise concerns, provide feedback, or file a complaint. Clients may use this process whether the concern is large or small, and may ask for support from a trusted person, advocate, interpreter, or staff member.
Doors of Change will not deny services, reduce services, treat a client differently, or retaliate against a client for raising a question, concern, or complaint in good faith.
2. Questions and Informal Concerns
Clients are encouraged to speak with their Case Manager, or another Doors of Change staff member when they have a question or concern. Staff will listen, provide clarification when possible, and make reasonable efforts to address the concern promptly.
A client may ask to speak with a supervisor or the Program Director at any time. Clients do not have to use an informal process before filing a formal complaint.
3. Filing a Formal Complaint
A client may submit a formal complaint verbally or in writing. Complaints may be made in person, by phone, by email, or by using the Client Questions, Concerns, and Grievance Form in Appendix A. A client may submit a complaint anonymously; however, Doors of Change may be limited in its ability to provide a direct response if no contact information is provided.
A client may submit a complaint to any Doors of Change staff member, supervisor, or the Program Director. Staff receiving a complaint must document it and promptly notify the Program Director or designee.
When available, a complaint should include:
- The client’s name and preferred contact information
- A description of the concern or complaint
- The date, location, and people involved
- Any requested outcome or resolution
Clients are not required to share information they do not feel safe sharing in order for Doors of Change to consider their concern.
4. Review and Response
The Program Director or designee will review each complaint promptly and fairly. The review may include speaking with the client, involved staff, and other people who have relevant information. Doors of Change will make reasonable efforts to provide an acknowledgment within five business days and a response or status update within fifteen business days.
If more time is needed, Doors of Change will provide an update whenever possible. A response may include clarification, corrective action, referral to another resource, staff coaching or training, or another appropriate resolution.
5. HMIS Privacy and Confidentiality Concerns
Clients may raise questions or concerns about their HMIS information, including collection, use, accuracy, privacy, security, or confidentiality. HMIS-related concerns will be reviewed by the Program Director or the agency’s designated HMIS Administrator. When appropriate, Doors of Change will coordinate with the Regional Task Force on Homelessness (RTFH) HMIS Lead Agency to address the concern.
Clients may request to review or correct information in accordance with applicable HMIS privacy procedures and the Notice of Privacy Practices.
6. Privacy, Accessibility, and No Retaliation
Doors of Change will handle client questions and complaints respectfully and will keep information private to the greatest extent possible. Information will be shared only with people who need it to review, investigate, or resolve the concern, or when disclosure is required by law or necessary to protect health or safety.
Doors of Change will make reasonable efforts to ensure this process is accessible. This may include providing interpretation, reading forms aloud, accepting verbal complaints, helping with written documentation, or providing another reasonable accommodation.
7. Staff Responsibilities and Recordkeeping
Staff must receive client questions and complaints respectfully, document formal complaints, promptly notify the Program Director or designee, and cooperate with any review. Formal complaint records and related responses will be maintained securely and used to identify opportunities to improve services, staff practices, and client experience.