participates in the Pasco County Continuum of Care (FL-519) Coordinated Entry System (CES) and/or the Pasco County Homeless Management Information System (HMIS). These systems include organizations that provide homeless and housing assistance and supportive services. As part of HMIS and the CES system, agencies agree to share information about individuals and familes with other agencies in order to coordinate services and help a household find and/or keep housing as quickly as possible.
The information to be disclosed may include personal information contained within the Pasco County Homeless Management Information System (HMIS), records from providers detailing my medical conditions and including information on disabilities, mental health, drug abuse, alcoholism, sickle cell anemia, human immunodeficiency virus (HIV) infection, AIDS, and other communicable disease test results and diagnoses. Information contained within the Vulnerability Index and Service Prioritization Decision Assistance Tool (VI-SPDAT), the Service Prioritization Decision Assistance Tool (SPDAT), other assessment forms, and other information collected as part of case management, case planning and case conferencing will be shared in HMIS and as it relates to the coordination of services for housing placement and stability.
Important Rights and Other Required Statements You Should Know
You can revoke this authorization at any time by writing to the Coalition for the Homeless of Pasco County, Inc., 8039 Youth Lane, Port Richey, FL 34668 or by email request to info@pascohomelesscoalition.org.
You have a right to a copy of this authorization once you have signed it. Please keep a copy for your records, or you may ask us for a copy at any time by writing to Coalition for the Homeless of Pasco County, Inc., 8039 Youth Lane, Port Richey, FL 34668 or by email request to info@pascohomelesscoalition.org.
If you have any questions about anything on this form, or how to fill it out, we can help. Please call the Coalition for the Homeless of Pasco County, Inc. at 727-842-8605.
This authorization will expire two (2) years from the date this document was signed by the individual or personal representative below.