BY SIGNING THIS CONSENT/AUTHORIZATION, I UNDERSTAND:
• UNITY allows information about me to be accessed by, shared with, and updated by any social service agencies using UNITY as needed for service delivery.
• Information about me may be shared and/or discussed to assist me with my housing needs. This means service providers, who may or may not have direct access to UNITY, may review and discuss information about me with each other in a meeting setting. The purpose of sharing this information is to help identify the right program for me based on eligibility and service need. Desired restrictions on data sharing can be submitted in writing to any agency that uses UNITY. Unless I place restrictions in writing on the agencies that may see information about me, all agencies using the UNITY will be able to see the information that this Agency inputs to UNITY. I understand that upon my request, this Agency must show me a list of the CoC member agencies participating in the UNITY Information Network at the time I sign this consent/authorization. I may also access the most current list at www.THHI.org/unity/.
• Social service agencies that join the UNITY after I sign this consent/authorization also will have access to the personal information I authorize for sharing through this consent/authorization. This Agency must make reasonable accommodations for me to view the updated list of CoC member agencies that may access my information pursuant to this consent/authorization for so long as this consent/authorization remains in effect.
• This form authorizes the transfer of my information, including personally identifying information, from UNITY Information Network to a data warehouse environment for coordination of care and data analysis.
• This form authorizes the use of my information in research conducted using information maintained in UNITY. I will not be personally identified by name, social security number, or any other unique characteristic in published research reports.
What rights do you have regarding your information?
• Inspect and obtain a copy of all your records in UNITY.
• Update information about you when the information in the UNITY record is inaccurate.
• Receive a list of people who have viewed your protected personal data in UNITY for the seven years prior to the date you request the information.
• Revoke your consent/authorization at any time.
You can exercise your rights by making a written request to this Agency.
Your consent/authorization will automatically expire seven (7) years from the date of this form in the event that you do not revoke your consent/authorization earlier. However, it is important to note that if your consent/authorization expires or is revoked, the expiration or revocation (as the case may be) shall not apply to any of my data or information that has already been collected.
If you believe that your privacy rights have been violated, you may submit a written complaint to this Agency or submit a written complaint to
UNITY Information Network
Tampa Hillsborough Homeless Initiative
P.O. Box 1110
Tampa, FL 33601
If you have additional questions that the person assisting you with this form cannot answer, you may contact UNITY Information Network Staff at 813-223-6115.
By signing below, I affirm that I have read this document or it was read and/or explained to me and I fully understand and agree with the terms of this document.