MSHMIS Combined Release of Information and Sharing Plan

Many Michigan shelters and helping programs use the Michigan Statewide Homeless Management Information System (MSHMIS) to keep information about the people that they help. We collect personal information from you that we need to help us, help you. We have strict rules about sharing your information.

Why do we collect information about you?

Work with other agencies to help you.
Help case managers work together for you.
Connect you with other helping agencies. You may be eligible for other benefits.
Reduce the number of times you tell your story.
Allow us to be paid for our work with you and to help us apply for additional dollars that can be used to help you.
Help us meet our legal obligations.

We need additional identifying information so that you are not confused with someone else. We also need to learn more about your situation to make sure you are eligible for services.

SECTION 1 - Basic Identifying Information

So that agencies that use our MSHMIS system can find your record, agencies can see the following basic identifying information about you:

Your name
Your gender
The last four digits of your Social Security Number
Your year of birth
Your veteran status

We use this information to select the correct record and to better coordinate services for you. All persons using MSHMIS are trained and certified in privacy.

If you have a specific reason why other MSHMIS agencies shouldn't be able to find your record in MSHMIS, you can ask to have this basic identifying information secured so that only our agency can see it.

PLEASE NOTE: If you have received services from other agencies who use MSHMIS we may not be able to secure this information. PLEASE TALK WITH YOUR CASE MANAGER for more information. A separate document has been attached

I have reviewed the attached document named "Securing Basic Identifying Information." I understand the implications and I am asking that my client profile be secured. Do not initial here unless you have discussed this with your case manager Please initial below to secure this basic identifying information.

Please initial here:*

SECTION 2 - Acknowledgement of Rights

Many agencies also use the system to improve services delivered to you. The following are your rights concerning your data. Please review and initial in the box next to each right to show that you understand it. If you have questions, please discuss them with your case manager.

Please read and initial the following:*

	Please Initial Here
I have received a copy of the Agency's Privacy Notice/Script that explains MSHMIS and my rights and responsibilities. It explains how information is kept and share through the system
I UNDERSTAND THAT THE CONFIDENTIALITY OF MY RECORDS IS PROTECTED BY LAW. I understand that this agency will never give information about me to anyone outside the agency without my specific written consent through a Coordination of Care Sharing Plan or as required by law, including the Federal Law of Confidentiality for Alcohol and Drug Abuse Patients, (42 CFR, Part 2), the Health Insurance Portability and Accountability Act of 1996 (HIPAA, 45 CFR, Parts 160 & 164 as revised by the Health Information Technology for Economic and Clinical health Act of 2009 aka the HITECH Act), and certain Michigan Laws.
I can withdraw my consent to share at any time, but any information already shared with another agency cannot be taken back. If sharing information on the system poses and imminent health or safety risk, I will talk with my case manager.
I understand that I have the right to see my information, request changes, and to get a copy of my information by written request. An agency can refuse to change my record but must provide a written explanation of why they refuse to change within 60 days. Agencies may charge for reproducing a record.
I understand that agencies included in my Sharing Plan must follow strict privacy guidelines.
I understand that my written consent allows the information listed in Section 3 - Coordination of Care Sharing Plan to be shared among the agencies listed in the sharing plan. All sharing agencies where I am receiving services will update that information as I provide new or additional information. the purpose of sharing my information is to better coordinate care for me and my family.
I understand that I will not be denied services (emergency assistance, outreach, shelter, housing assistance, etc.) if I refuse to share information in this system.
I understand that my name and other identifying information may be used to match the records through a trusted partner for academic research purposes or to determine eligibility for other resources. If I am eligible to receive additional resources, my case manager may contact me. None of my additional identifying information outside of my name will be shared with other organizations unless I sign an additional release of information. Prior to academic research being done, my identifying information will be removed, before data analysis takes place.

SECTION 3 - Coordination of Care Sharing Plan

The information (listed below) can be seen by the following agencies to help corrdinate your care. These agencies can share your information with each other.

Sault Ste Marie Housing Commisssion
Hiawatha Behavioral Health
Medical Hospital/Clinics
Bay Mills Tribe
City/County Law Enforcement/Legal System
Red Cross
Sault Ste Marie Tribe of Chippewa Indians
NAMA (Newberry Area Ministerial Association)
Offenders Success
Diane Peppler Resource Center
Unted Way of the EUP
Michigan Works
Salvation Army
Veteran Services/SSVF/AMCAB/Oscar G Johnson Medical Center
Chippewa County Health Department/LMAS Health Department
West Bridge Apartments
Great Lakes Recovery Centers

In addition to the Basic Identifying Information listed in Section 1 above, additional shared information also includes:

Date of birth
Household members and relationships
Physical, developmental, and/or mental disability
Household income and benefits
Military service information
Domestic violence history
Services and financial asistance with dates
Eviction/loss of subsidy
HUD-VASH Voucher tracking
Case plans, goals and notes
Race and ethnicity
Housing status, homeless history and move-in date
HIV/AIDS including T-cell and viral load
Chronic health conditions
Employment
Project exit and destination
Referrals and service connections
Registered sex offender
HUD-VASH exit reason
Eligibility documentation
Additional assessment responses
Current Living Situation and General Location
Type of health insurance and/or medical assistance
Alcohol and/or drug abuse
Education level
Exit housing assessment
Location (city, county) and last permanent address
Contact information
VI SPDAT/Housing Screening Tools
General health status

Instructions: Check the box next to the statement that you understand and agree to:

I agree to have my information visible to all of the helping agencies listed above.*

Yes, I agree to share according to the Coordination of Care Sharing Plan.No, I do not agree to the Coordination of Care Sharing Plan (only our agency will be able to see all your detailed information.

SECTION 4 - Outreach Sharing Plan

We partner with Michigan community programs to see if you might qualify for housing or income supports.

Please read each statement and select your response to the question following the statement.

1. Secretary of State ID Project:

If you don't have a State ID, the Secretary of State is accepting the MSHMIS ServicePoint ID card with AN AGENCY REFERRAL as initial proof of your identity. To do that, the Secretary of State will need to ensure that your card is genuine by verifying your information with the MSHMIS agency serving you.

Information that will be shared includes: Name, date of birth, and Social Security Number.

1. Secretary of State ID Project: Do you agree to share HMIS data for the Secretary of State Project?*

YesNoN/A

2. Veteran Affairs:

If you have served in the military, the VA Medical Center may contact you about potential housing. With your permission, they may use the information you give this agency to contact you.

Information that will be shared includes: Name, date of birth, homeless status, veteran status, military service information, housing history, contact information, chronically homeless status.

2. Veteran Affairs: Do you agree to share HMIS data for the Veteran's Project?*

YesNoN/A

3. MDHHS Income and Benefits:

Income and benefits are important to staying housed. The Michigan Department of Health and Human Services (MDHHS) may assist with obtaining Social Security Income and/or other state benefits, if you qualify. With your permission, they may use the information you give this agency to contact you, if you are eligible for benefits.

Information that will be shared includes: Name, date of birth, coordinated assessment information, homeless status, housing history, contact information, chronically homeless status.

3. MDHHS Income and Benefits: Do you agree to share HMIS data for the Social Security or other state benefits?*

YesNoN/A

4. Housing Review Committee/Housing Prioritization:

If you are homeless you may be eligible for housing in our community. We have a housing review committee made up of representatives from our service providers. To participate in this process, these providers may need to see your information. With your permission, an agency may contact you if your information shows that you may be eligible for local housing services. A list of service providers involved in this process is available on request.

Information that may be shared includes: Name, coordinated assessment information, homeless status, chronically homeless status, veteran status, disability and any additional information that may be used to connect you with appropriate housing options.

4. Housing Review Committee/Housing Prioritization: Do you agree to share information with the housing review committee?*

YesNoN/A

5. Homeless history:

We may need to document your homeless history throughout the state of Michigan to see if you are eligible for specific community programs. Your case manager may contact the Michigan Coalition Against Homelessness (MCAH, the MSHMIS lead agency) to view data recorded in HMIS to complete a housing history document. With your permission, MCAH will complete the document and give it to your case manager. This document may be uploaded to your client record and shared according to the coordination of the care sharing plan.

Information that will be shared includes: HMIS number, name, and a 3-year statewide homeless history that includes service provider names and dates of service.

5. Homeless history: Do you agree that MCAH may share data with your Case Manager?*

YesNoN/A

6. Medicaid Benefits:

If you are already a Medicaid beneficiary or could be eligible for Medicaid, the regional organization responsible to provide you those benefits or can enroll you for those benefits may contact you about potential healthcare services. With your permission, they may use the information you give this agency to contact you, if you are eligible for benefits.

Information that will be share includes: Name, date of birth, coordinated assessment information, homeless status, housing history, contact information, chronically homeless status.

6. Medicaid Benefits: Do you agree to share HMIS data for Medicaid benefits?*

YesNoN/A

Client signature (head of household):*

Adult Household Member signature:

Signature of guardian or authorized-representative (when required):

Relationship to client:

Please verify that you are human*

EUP Michigan/CLM Community Action Agency MSHMIS