HMIS Agency Agreements and Client Consent Forms
The Homeless Missourians Information System (HMIS) Steering Committee has developed a set of operating forms for your agency’s use with the HMIS database. The forms are required to be used by all participating agencies, and are described below (Adobe Acrobat Reader is required… click here to get the FREE Adobe Acrobat Reader).
To see and print each form, click on the title of the form. These forms can also be obtained from the ICA Missouri HMIS Project by emailing or calling your System Administrator:
- Krystal Searcy, Senior System Administrator (BoS CoC Regions 4, 5, & 10) - 573-298-6066 x2
- Rachel Gladow, System Administrator (Bos CoC Regions 1, 2, 3, 6, & 7) - 573-298-6066 x1
- Michael Tonarely, System Administrator (Jasper/Newton CoC; Springfield CoC; BoS CoC Regions 8 & 9) - 573-298-6066 x4
- Isaac Fox-Poulsen, System Administrator (St. Louis City CoC) - 314-655-4778
- Lacy Peterson, System Administrator (St. Louis City CoC) - 314-655-4777
- Katie Wiseman, System Administrator (St. Louis County CoC) - 314-655-4779
These forms are updated periodically. If you are a participating partner agency, your agency will be notified by email when an updated version of any form is available.
This form is an agreement between your agency and the Institute for Community Alliances (ICA), the agency that received the grant from HUD to administer the HMIS. 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.
The Executive Director of your agency, or a person with similar responsibility, should read and sign this form. The original form must be signed in blue ink and returned to the ICA Missouri HMIS Project before your agency will be granted access to the HMIS database. The agency should keep a copy for their files. The form must be mailed to 2415 Hyde Park RoadJefferson City, MO 65109.
Individuals working on behalf of an agency (employee, contractor or volunteer) that will be accessing HMIS must be designated as an HMIS User. HMIS Users are designated by the Partner Agency’s Executive Director or authorized representative.
For training requirements, please contact your System Administrator until new training documents are available.
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.
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.
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.
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.
The agency will modify the form to reflect the agency’s information per the instructions. Once completed the original form will be mailed to HMIS office with a copy maintained at the agency’s office. Mail to: 2415 Hyde Park Road, Jefferson City, MO 65109.
Data Collection Forms
- HMIS Core Data Collection Forms (WORD)
- HMIS UDE Data Collection Forms (WORD)
- HMIS MHDC Funded Program - Specific Data Collection Forms (WORD)
- HMIS HUD Funded Program - Specific Data Collection Forms (WORD)
- HMIS RHY Funded Program - Specific Data Collection Forms (WORD)
- HMIS SSVF Funded Program - Specific Data Collection Forms (WORD)
- HMIS Veteran Information Adult-HoH Data Collection Form (WORD)