Common use of Manager License Clause in Contracts

Manager License. The Clarity Manager license is a license that includes access to agency/program management features and Clarity’s data analysis interface, Looker. One user per agency is required to be assigned a Manager license; by default the Manager license will be assigned to the agency’s primary HMIS administrator. Additional Manager licenses may be purchased/assigned upon request by the agency. Fee Structure for Clarity Licenses Type of License Fee Structure Clarity Enterprise User License Initial Setup Fee: $175/new user license Monthly access fee (to be billed on a quarterly basis): $25/user license *All HMIS licensing fees are subject to change. Clarity Manager License Initial Setup Fee: $250/new Manager license Monthly access fee (to be billed on a quarterly basis): $55/Manager license *All HMIS licensing fees are subject to change. Data Quality Incentives RTFH may provide data quality incentives in the form of HMIS fee discounts. These incentives are not fixed or regular and will be provided and announced on an ad hoc basis. Information on incentives will be shared with providers once confirmed for each billing cycle. Waiver Policy Statement Waiver (or reduction) of fees for hardship may be submitted to RTFH and may be granted upon review. Requests for waivers must be submitted prior to the start of the upcoming billing cycle, so by January 1st of the year a waiver is being requested for. Fees for other Requests Other requests, including but not limited to custom reporting, data export/import and data integration projects, will be considered on a case-by-case basis. Cost estimates will be developed based upon a statement of work for the requested project. Payment Methods Checks and money orders are the only acceptable payment methods for HMIS licensing fees. 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: San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information • 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 • 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 xxxxx://xxx.xxxxxx.xxx/what-we-do/homelessmanagement- information-system-hmis/ and sending it to RTFH at: xxxxxxx@xxxxxx.xxx or by mailing it to the Regional Task Force on the Homeless, 0000 Xxxxxx Xxxxxx 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 xxxxx://xxxxxxxxxxx.xxx/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 n d i f I do not sign this Authorization, then my receipt of housing or other services may be limited or delayed. San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information 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.

Manager License. The Clarity Manager license is a license that includes access to agency/program management features and Clarity’s data analysis interface, Looker. One user per agency is required to be assigned a Manager license; by default the Manager license will be assigned to the agency’s primary HMIS administrator. Additional Manager licenses may be purchased/assigned upon request by the agency. Fee Structure for Clarity Licenses Type of License Fee Structure Clarity Enterprise User License Initial Setup Fee: $175/new user license Monthly access fee (to be billed on a quarterly basis): $25/user license *All HMIS licensing fees are subject to change. Clarity Manager License Initial Setup Fee: $250/new Manager license Monthly access fee (to be billed on a quarterly basis): $55/Manager license *All HMIS licensing fees are subject to change. Data Quality Incentives RTFH may provide data quality incentives in the form of HMIS fee discounts. These incentives are not fixed or regular and will be provided and announced on an ad hoc basis. Information on incentives will be shared with providers once confirmed for each billing cycle. Waiver Policy Statement Waiver (or reduction) of fees for hardship may be submitted to RTFH and may be granted upon review. Requests for waivers must be submitted prior to the start of the upcoming billing cycle, so by January 1st of the year a waiver is being requested for. Fees for other Requests Other requests, including but not limited to custom reporting, data export/import and data integration projects, will be considered on a case-by-case basis. Cost estimates will be developed based upon a statement of work for the requested project. Payment Methods Checks and money orders are the only acceptable payment methods for HMIS licensing fees. 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: San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information • 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 • 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 xxxxx://xxx.xxxxxx.xxx/what-we-do/homelessmanagement- information-system-hmis/ and sending it to RTFH at: xxxxxxx@xxxxxx.xxx or by mailing it to the Regional Task Force on the Homeless, 0000 Xxxxxx Xxxxxx 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 xxxxx://xxxxxxxxxxx.xxx/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 n d i f I do not sign this Authorization, then my receipt of housing or other services may be limited or delayed. San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information 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.Methods

Manager License. The Clarity Manager license is a license that includes access to agency/program management features and Clarity’s data analysis interface, Looker. One user per agency is required to be assigned a Manager license; by default the Manager license will be assigned to the agency’s primary HMIS administrator. Additional Manager licenses may be purchased/assigned upon request by the agency. Fee Structure for Clarity Licenses Type of License Fee Structure Clarity Enterprise User License Initial Setup Fee: $175/new user license Monthly access fee (to be billed on a quarterly basis): $25/user license *All HMIS licensing fees are subject to change. Clarity Manager License Initial Setup Fee: $250/new Manager license Monthly access fee (to be billed on a quarterly basis): $55/Manager license *All HMIS licensing fees are subject to change. Data Quality Incentives RTFH may provide data quality incentives in the form of HMIS fee discounts. These incentives are not fixed or regular and will be provided and announced on an ad hoc basis. Information on incentives will be shared with providers once confirmed for each billing cycle. Waiver Policy Statement Waiver (or reduction) of fees for hardship may be submitted to RTFH and may be granted upon review. Requests for waivers must be submitted prior to the start of the upcoming billing cycle, so by January 1st of the year a waiver is being requested for. Fees for other Requests Other requests, including but not limited to custom reporting, data export/import and data integration projects, will be considered on a case-by-case basis. Cost estimates will be developed based upon a statement of work for the requested project. Payment Methods Checks and money orders are the only acceptable payment methods for HMIS licensing fees. San Diego County CoC Homeless Management Information System (HMIS) HMIS)‌ Multiparty Authorization to Use and/or Disclose Information To Receive Coordinated Care, Referrals Client/Head of Household Name Date of Birth HMIS # Mailing Address/Place of Stay Phone Number Email I am requesting the following information (historical 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 (HMISup to the date of expiration) 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 Diegoadded to the Homeless Management Information System (HMIS), and Participating Agencies shared with the authorized recipient organizations described herein for purposes that they include supporting our efforts to provide coordinated housing and comprehensive services. The data elements authorized to be shared include:  My Name  My Destination  Any Developmental   My Age My Social Security Number   My Relationship to Head of Household My Location  Disability Any Chronic Health Condition       My Veteran Status My Personal ID My Household ID My Date of Birth My Race My Ethnicity    My Length of time on the Street, in an Emergency Shelter or Safe Haven My Housing Status My Income Sources      HIV/AIDS condition Mental Health condition Substance Abuse Domestic Violence VISPDAT assessment and score  My Gender  Any Non-Cash Benefits  My answers to locally  Any Disabling Condition  My Residence Prior to Project Entry  My Health Insurance  Any Physical Disability required questions  Documents necessary for housing placement Sensitive Information: I understand that the information I provide may refer me to come from mental health or who may already be providing me with services to collectalcohol and drug abuse treatment programs. RTFH will employ administrative, record, usetechnical, and share my personally identifiable healthphysical safeguards to protect sensitive information collected under this agreement. Right to Revoke: I understand that I have the right to revoke this authorization, financialin writing, housing, employment, at any time. I understand that the revocation will not be retroactive and will not apply to information that has already been released or until the service provider receives the revocation. I understand that revocation of this authorization may limit referrals to housing and/or 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 that may be available 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: San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information • 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 • 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 xxxxx://xxx.xxxxxx.xxx/what-we-do/homelessmanagement- information-system-hmis/ and sending it to RTFH at: xxxxxxx@xxxxxx.xxx or by mailing it to the Regional Task Force on the Homeless, 0000 Xxxxxx Xxxxxx 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 xxxxx://xxxxxxxxxxx.xxx/revoke/ Expiration/Renewal: Unless otherwise revoked, to the fullest extent allowed by law, this Authorization authorization shall remain valid for seven (7) years from the Effective Date indicated belowyears. This Authorization 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 authorization is required for RTFHmy disciplinary treatment team to coordinate care, 2-1-1 San Diegoor for housing needs, and the Participating Providers to provide coordinated referrals and services a n d i f I do not sign this Authorization, then my receipt of treatment and/or housing or other services may be limited or delayedlimited. San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization I authorize RTFH to Use and/or Disclose Information Right de-identify the information described above and share such information for research purposes and in furtherance of RTFH’s mission to a Copy of My Information: provide comprehensive data and trusted analysis that empowers the entire community to identify, implement, and support efforts to prevent and alleviate homelessness. 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 of this Authorizationauthorization. Check here to receive a copy: Authorized Recipient Organizations: Page three (3) contains a list of HMIS Participating Agencies that can receive my data under this agreement, and that are authorized to use or disclose the information described above for purposes related to and including supporting efforts to provide coordinated housing and comprehensive services. This list of authorized recipient organizations may be updated periodically. The complete and updated list of authorized recipient organizations will be posted on the RTFH website at xxxx://xxx.xxxxxx.xxx. RTFH and authorized recipient organizations shall only use the information described above in compliance with all applicable laws. Signature of Individual or Legal Representative Client Signature Client Name Date If signed by Legal Representative, Relationship to Individual I do not wish to share information with any organizations: San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information 2-1-1 San Diego Affirmed Housing Alpha Project for the Homeless Bread of Life Bridge Housing Corporation Catholic Charities City of Oceanside City of San Diego Homeless Outreach Team Cloudburst Community Catalysts of California/ Veteran Community Services Community Housing Works Community Resource Center Community Research Foundation ConAm Management County of San Diego Health and Human Services Agency Crisis House Department of Housing and Urban Development and its contractors Downtown San Diego Partnership East County Transitional Living Center Episcopal Community Services Escondido Education COMPACT Family Health Centers of San Diego F.P.I. Management Generate Hope Home Start, Inc. Housing Development Partners of San Diego Housing Innovation Partners Xxxxx Co. Impact Lab Institute for Public Health, San Diego State University Interfaith Community Services Interfaith Shelter Network Lutheran Social Services XxXxxxxxx Institute Mental Health Systems, Inc. Operation Hope NAMI San Diego North County Solutions for Change People Assisting the Homeless Pathfinders of San Diego, Inc. Pathways Catalyst Presbyterian Urban Ministries Public Consulting Group ResCare Royal Property Management Second Chance South Bay Community Services San Diego Housing Commission San Diego Rescue Mission, Inc. San Diego Youth Services Serving Seniors Xxxxxx Enterprises San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information St. Paul’s PACE St. Xxxxxxx xx Xxxx Village Telecare Corporation Think Dignity Travelers Aid Society of San Diego The Salvation Army The San Diego LGBT Community Center Townspeople Union of Pan Asian Communities Vista Hill Volunteers of America Southwest Veterans Administration San Diego Veterans Village of San Xxxxx Xxxxxxxx Housing and Development Corp. Women's Resource Center YMCA of San Diego County YWCA of San Diego County San Diego County CoC Homeless Management Information System (HMIS)‌ User Agreement First and Last Name Job Title E-mail Address Phone Number with Extension Agency HMIS Provider ID # and Project Name for my Default Provider Other HMIS Provider ID #’s and Project Names I need EDA access to Please check with your supervisor for Provider ID # and Project Name information Training Date Purpose The HMIS recognizes the priority of client needs in the design and management of the HMIS. These needs include both the need to continually improve the quality of homeless and housing services with the goal of eliminating homelessness in San Diego County, and the need to vigilantly maintain client confidentiality, treating the personal data of our most vulnerable populations with respect and care. As the guardians entrusted with this personal data, HMIS end-users have a moral and a legal obligation to ensure that the data they collect is being collected, accessed, and used appropriately. It is also the responsibility of each employee, volunteer, and any other person with access to the HMIS to ensure that client data is only used to the ends to which it was collected, the ends that have been made explicit to clients and are consistent with the mission of the HMIS, to use the HMIS to advance the provision of quality services for homeless person, improve data collection, and promote more responsive policies to end homelessness in San Diego County. Proper user training, adherence to the HMIS Policies and Procedures, and a clear understanding of client confidentiality and HMIS user responsibility are vital to achieving these goals. Client Confidentiality  A Multiparty Authorization form must be signed by each client whose data is to be shared within the HMIS. Client authorization may be revoked by that client at any time through a written notice.  No client may be denied services for failure to provide authorization for HMIS data collection. Clients have a right to inspect, copy and request changes in their HMIS records.  HMIS end-users may not share HMIS client data with individuals or agencies that have not entered into an HMIS Agency Participation Agreement or obtained written permission from that client.  Excluding information shared in the client profile, HMIS users may not share client data with any agency that is not specified without obtaining a written permission from the client.  HMIS end-users will maintain HMIS data in such a way as to protect against revealing the identity of clients to unauthorized agencies, individuals or entities.  Personal User Identification (User ID) and Passwords must be kept secure and are not to be shared.  Confidential information obtained from the HMIS is to remain confidential, even if the individual’s relationship with the participating agency changes or concludes.  Misrepresentation of the client data by entering known or inaccurate information is prohibited. Any information that is not given by the client should be marked unknown.  Discriminatory comments based on race, color, religion, national origin, ancestry, handicap, age, sex and sexual orientation are not permitted in the HMIS. Profanity and offensive language are not permitted in the HMIS.  The HMIS is to be used for business purposes only. Transmission of material in violation of Federal or California State regulations or laws is prohibited and includes material that is copyrighted, and/or judged to be threatening or obscene. The HMIS will not be used to defraud the Federal, State, or local government or an individual entity or to conduct any illegal activity.  Any HMIS end-user found to be in violation of the HMIS Policies and Procedures, or the points of client confidentiality in this User Agreement, will result in immediate suspension of access to the HMIS and may jeopardize your employment status with the participating agency. San Diego County CoC Homeless Management Information System (HMIS) User Agreement Ethics These general principles form the ethical or professional standards of conduct necessary for access to HMIS. Each end- user shall adhere to the delivery of services with the highest standards of professionalism, integrity, and competence.

Manager License. The Clarity Manager license is a license that includes access to agency/program management features and Clarity’s data analysis interface, Looker. One user per agency is required to be assigned a Manager license; by default the Manager license will be assigned to the agency’s primary HMIS administrator. Additional Manager licenses may be purchased/assigned upon request by the agency. Fee Structure for Clarity Licenses Type of License Fee Structure Clarity Enterprise User License Initial Setup Fee: $175/new user license Monthly access fee (to be billed on a quarterly basis): $25/user license *All HMIS licensing fees are subject to change. Clarity Manager License Initial Setup Fee: $250/new Manager license Monthly access fee (to be billed on a quarterly basis): $55/Manager license *All HMIS licensing fees are subject to change. Data Quality Incentives RTFH may provide data quality incentives in the form of HMIS fee discounts. These incentives are not fixed or regular and will be provided and announced on an ad hoc basis. Information on incentives will be shared with providers once confirmed for each billing cycle. Waiver Policy Statement Waiver (or reduction) of fees for hardship may be submitted to RTFH and may be granted upon review. Requests for waivers must be submitted prior to the start of the upcoming billing cycle, so by January 1st of the year a waiver is being requested for. Fees for other Requests Other requests, including but not limited to custom reporting, data export/import and data integration projects, will be considered on a case-by-case basis. Cost estimates will be developed based upon a statement of work for the requested project. Payment Methods Checks and money orders are the only acceptable payment methods for HMIS licensing fees. San Diego County CoC Homeless Management Information System (HMIS) 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: San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information • 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 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/ Decline/Revocation form found at xxxxx://xxx.xxxxxx.xxx/what-we-do/homelessmanagement- xxxxx://xxx.xxxxxx.xxx/what-we-do/homeless- management-information-system-hmis/ and sending it to RTFH at: xxxxxxx@xxxxxx.xxx or by mailing it to the Regional Task Force on the Homeless, 0000 Xxxxxx Xxxxxx 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 xxxxx://xxxxxxxxxxx.xxx/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 n d i f I do not sign this Authorization, then my receipt of housing or other services may be limited or delayed. San Diego County CoC Homeless Management Information System (HMIS) Multiparty Authorization to Use and/or Disclose Information 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.