What this agreement does:
This Authorization and Disclosure Agreement explains how Montana Queer Alliance, Common Ground Housing collects, uses, and shares information you provide in your housing application and during housing related services. It also describes your rights.
Why we collect information:
Common Ground Housing collects information to:
• Determine eligibility for housing assistance and related supports
• Match you with appropriate resources, referrals, and partner services
• Coordinate care and services across housing, health, and basic needs supports when you choose to participate
• Meet reporting requirements for funders and program oversight
• Improve the quality, safety, and accessibility of our services
What information may be collected
Information may include:
• Identifying information like your name, date of birth, contact information, and household information
• Housing history, current housing status, and barriers to housing
• Income, employment, benefits, and insurance information
• Safety and crisis related information that helps us plan for support needs
• Limited health related information you choose to share that is relevant to housing stability, such as mobility needs, mental health supports, substance use recovery supports, or daily living needs
• Documentation you submit, such as IDs, pay stubs, benefit letters, lease documents, eviction notices, or verification letters
• Notes about services provided, referrals made, and outcomes related to housing support
How your information may be used and shared
With your authorization, Common Ground Housing may share information with partner organizations only as needed to support your housing goals. This may include sharing information to:
• Request or confirm available housing options
• Coordinate referrals for shelter, transitional housing, rental assistance, or supportive housing
• Connect you to services such as medical care, behavioral health care, substance use treatment, peer support, domestic violence services, food resources, utility support, legal aid, transportation support, and benefits navigation
• Verify information required by a landlord, housing provider, or assistance program
• Coordinate emergency supports, when needed and appropriate
We share the minimum necessary information to support coordination and referrals.
Disclosures that may occur without your authorization Common Ground Housing may disclose information without your written authorization only when required or allowed by law, such as:
• If there is suspected abuse or neglect of a child, elder, or vulnerable adult and a report is required
• If there is an immediate threat of serious harm to you or someone else and information is needed to reduce danger
• If required by a valid court order, subpoena, or other legal process
• For audits, monitoring, evaluation, or compliance reviews by funders or oversight entities, using privacy safeguards
• For internal operations such as quality improvement, training, or program evaluation, using safeguards and limiting access
Your choices and rights
You have the right to:
• Ask what information we have about you and request a copy of your records, subject to program policy and applicable law
• Ask us to correct information that is inaccurate or incomplete
• Choose not to answer certain questions, though that may limit our ability to determine eligibility or make referrals
• Refuse to sign this agreement. You will not be punished for refusing, but we may be unable to coordinate certain referrals or supports without your authorization
• Withdraw your authorization at any time by submitting a written request. Withdrawal applies going forward and does not undo disclosures already made
• Request information about our privacy practices and how we protect your information
Important safety note for survivors
If you are currently fleeing, in danger, or concerned that sharing information could increase risk related to domestic violence, dating violence, sexual assault, stalking, trafficking, or another safety concern, tell staff. We will discuss safer options for documentation, confidentiality, and referrals.
Consent duration
This Authorization remains in effect until one of the following occurs:
• You withdraw it in writing via mail, email, or text message.
• The Common Ground Housing program closes your case due to inactivity based on program policy or eligability.
• The expiration date listed below is reached.
How to withdraw this authorization or ask questions
To withdraw your authorization or request information about privacy:
Montana Queer Alliance, Common Ground Housing
Attn: Privacy and Records
Mailing address: 515 N Ewing Street, Helena, MT 59601
-or-
E-Mail: contact@montanaqueeralliance.org
-or-
Text: 406-201-9814