Agency Partner Agreement

This form is an agreement between your agency and the Institute for Community Alliances (ICA), the HMIS Lead for the MoHMIS. The form describes our mutual responsibilities in connection with the use of the HMIS database. It spells out many of the duties of the partner agency as a whole toward maintaining the confidentiality of client information.

Procedure:

This form must be completed before the agency is provided with access to the database, and again each August. Complete the Agency Partner Agreement using the links below.  It must be completed by the agency's Executive Director (or equivalent). If your agency provides services in more than one of the following regions, your Executive Director must complete the agreements for each region. 

Note: This form is digital and you will be directed to DocuSign to complete the form. If you have any questions about completing the form, please contact the helpdesk.

 

Designation of HMIS Contacts and Authorized Representatives (optional)

This form can be utilized by Executive Directors to designate additional contacts and representatives for the agency and its projects. While this form is optional, if it is not completed only the Executive Director will be able to sign User Access Request forms and New Project Request forms. Any forms submitted by an individual not designated as an authorized representative will be rejected. 

Note: This form is digital and you will be directed to Formstack to complete the form. If you have any questions about completing the form, please contact the helpdesk.

 

User Access Request

On the User Access Request form, the Executive Director (or other authorized designee) indicates what project(s) each individual needs to be able to access, provides the individual's contact information, and a couple more details about the user's access to the HMIS. This is used by ICA System Administrators to follow up with the individual to complete the User Policy and Responsibilities form, as well as ensure the user has proper training to complete the data entry required.

This form is utilized to initiate training for new users, and must also be completed each August for each current user to maintain access. It must also be completed any time an individual's access rights to the HMIS should be modified (e.g., change in job responsibilities, transfer to a different department).

Note: This form is digital and you will be directed to Formstack to complete the form. If you have any questions about completing the form, please contact the helpdesk.

 

User Policy and Responsibilities

On this form, the end user agrees to follow all HMIS policies and responsibilities. This form must be completed before the user is provided with training and access to the system, and again each August to maintain access to the HMIS. 

Note: This form is digital and you will be directed to Formstack to complete the form. If you have any questions about completing the form, please contact the helpdesk.

 

Privacy and Security Notice (Revised June 2011)

This notice describes the HMIS privacy policy of your agency.  The information collected by your agency includes:  basic identifying demographic data, such as name, address, phone number and birth date; the nature of the clients situations and the services and referral they receive from your agency.  This information is known as the clients Protected Personal Information or PPI.  All agencies which utilize the HMIS share their data with other participating agencies, with the exception of Protected Class Agencies. Protected agencies service specific protected client populations, such as HIV/AIDS, alcohol and/or substance abuse, and mental health, and do not share program information.  All clients served by your agency is covered by this policy.

Procedure:

This document will need to be edited on page three and page four.  Make sure that you edit the “Header” and add your agency name.  When completed return a copy of the HMIS Data Privacy Policy to the HMIS Project office via email and then place a copy into your HMIS Policies and Procedures binder or file.  All Agencies must provide a copy of the Privacy and Security Notice with the client should they request one.

 

Client Informed Consent to Share and Release of Information (Revised january 2017)

By signing the Client Informed Consent to Share and Release of Information form, the client understands that any information s/he shares with an agency participating in HMIS is kept confidential and that only those authorized to input data into HMIS can view their personally identifying information; all health information, however, will not be shared. By signing this form, the client also understands s/he has the right to refuse to answer a certain question in HMIS and, furthermore, that if s/he decides at a later date they no longer want their information to be in HMIS, that s/he can request it be removed.

Procedure:

Projects, unless otherwise exempted, must obtain a signed Client Informed Consent to Share and Release of Information form from every client who will be entered into HMIS.  Maintain the original, signed Client Informed Consent to Share and Release of Information form in client’s hard copy file. Agency will continue to maintain the original, signed Client Informed Consent to Share and Release of Information form for each client entered into HMIS for a minimum of three years from client’s program exit date.

 

HMIS Consumer Notice (Revised November 2016)

The HMIS Project Consumer Notice explains to the client the Partner Agency participates in the HMIS Project. This notice must be placed in a visible area where clients will have the opportunity to view it.

 

HMIS Technology Equipment Reuse and Disposal Policy

Any computer, printers, copiers and fax machines that will no longer be used to access HMIS will have its hard drives reformatted multiple times before being used again by the Partner Agency or anyone else. A computer that is being disposed of will have its hard drives permanently destroyed and disposed of in a secure manner.

Procedure:

The agency will modify the form to reflect the agency’s information per the instructions.  Once completed the original form will be mailed to the local ICA office with a copy maintained at the agency’s office.  For more information, please contact the helpdesk.