Enrollment Form

Consent to Enroll

Please read carefully - case managers, please ensure you review this carefully with your client before they sign.
By signing below, I, {clientName600}, consent to being screened for and enrolled in programming at Anything Helps, and grant permission to share my personal information with healthcare and social service professionals if necessary for enrollment. I understand that the personal information I have disclosed in this form will only be used for this purpose, and certify that all information provided is true and correct to the best of my knowledge at the time of signing.
I grant Anything Helps permission to assist with my Washington Apple Health/Medicaid enrollment or renewal as my Washington Healthplanfinder Navigator. If I am eligible for Medicaid and have never been enrolled, or if I have been disenrolled from the Washington Apple Health Program, I understand that Anything Helps will contact me to help me activate or re-activate my Medicaid benefit plan, If I choose to do so. This may involve completing and submitting necessary documentation on my behalf.

I also grant Anything Helps permission to:
- Receive and review personal information related to my eligibility for Medicaid and other benefits.
- Use the Washington State Patrol’s Washington Access to Criminal History (WATCH) database for the exclusive purpose of determining my eligibility for Anything Helps programming.
- Receive copies of Washington Helathplanfinder notifications at their office address, if I cannot currently provide or do not have a residential address.
I acknowledge the potential risks related to sending and receiving unencrypted personal information, as relevant to my selected communication preferences. I understand that I may update or withdraw my consent, change my attestations, or modify this agreement at any time by contacting Anything Helps (1-206-880-1777) or Washington Healthplanfinder (1-855-923-4633).
I attest that I have experienced homelessness for the last 12 months in a place not meant for human habitation, in a safe haven, or in an emergency shelter;
OR I have been homeless on at least four separate occasions in the last three years, for a total of at least 12 months;
OR I previously met one of these definitions and have been housed for less than 60 days.

I understand that if I have been housed for more than 60 days, I may not meet the definition of chronic homelessness, but I may still be eligible for program enrollment.
Client Name*
Legal First and Last Name
Authorized Representative (If Applicable)

First NameLast Name
Authority of Representative to sign on behalf of the Client

ParentLegal GuardianCourt OrderOther
Signature of Client or Representative Authorized by Law*

Clear
Date Signed*

MonthDayYear
I certify that I, {typeA605}, am a duly authorized FCS intake worker with Anything Helps and have adhered to my agency’s policies, procedures, and Washington State Health Care Authority guidelines to obtain consent from {clientName600} for the purposes of establishing chronic homelessness eligibility and enrollment into the FCS program.

I attest that {clientName600} meets the duration and frequency requirements of chronic homelessness or previously met the HUD definition of chronic homelessness but has been housed within the last 60 days. {clientName600} has lived in a place not meant for human habitation, in a safe haven, or in an emergency shelter for at least 12 months, or at least on four separate occasions in the last three years with a combined length of at least 12 months.
Case Manager Signature

Clear
Date

MonthDayYear
Date
ROI End Date

MonthDayYear
Date
Monday.com Case Manager Text Function
Client Name

First NameLast Name
Monday.com Case Manager Text

Authorization to Disclose, Release and/or Obtain Protected Health Information

Please review this form thoroughly before signing. Your signature will grant Anything Helps permission to cast a wider net and exchange your personal information with a variety of entities and individuals that may be instrumental in delivering prompt and effective services to you.
It may be necessary for Anything Helps to request, use, exchange, and disclose your Personally Identifiable Information (PII) and Protected Health Information (PHI) with certain entities to advocate on your behalf and to deliver the assistance necessary to support your goals.These entities may include:

☑ Homeless Service Providers: Emergency shelters, transitional housing programs, rental subsidy programs, and outreach teams.
☑ Permanent Housing Providers: Property managers, landlords, public housing authorities, and supportive housing programs.
☑ Employers: Current, former, and prospective employers for employment verification or job placement.
☑ Legal Entities: Department of Corrections, legal representatives, parole officers, and court-appointed entities to assist with legal representation or compliance. Anything Helps will not act as your legal representative, nor will it disclose your location to law enforcement or any entity that could cause you harm.
☑ Government Agencies & Third-Party Contractors: Entities such as the City of Seattle, United Way, and designated agencies and indipendent contractors providing services and emergency assistance.
☑ Social Support: We may use your first name or the alias you disclose to us in order to locate and communicate with you about time-sensitive opportunities related to your goals.

Under this authorization, Anything Helps may disclose and/or obtain the following types of information to provide housing and employment services:

☑ Personal Information: Name, date of birth, and contact details.
☑ Health Information: Details related to your physical and mental health, substance use, medical history, or treatment relevant to service provision.
☑ Housing History: Information about your past and present housing status.
☑ Employment Information: Employment history, education, certifications, and references.
☑ Criminal Justice Information: Details necessary to identify, address, and manage potential barriers to housing and employment.

Once signed, this authorization remains valid until {roiEnd}. If no date is listed, this authorization will expire one year from the date of signing.

You have the right to:

Revoke Authorization: Withdraw your consent at any time by providing written notice to Anything Helps.

Access Information: Request and obtain a copy of your data, with access provided within 30 days.

Request Restrictions: Request limits on certain uses and disclosures of your information at any time.

Confidential Communications: Request communication through alternative means or locations.

Accounting of Disclosures: Receive an accounting of certain PHI disclosures made without your authorization.

Amend Information: Request Corrections to your PHI if it is inaccurate or incomplete.

By signing below, you authorize Anything Helps to manage the above information as disclosed in order for us to provide you with effective assistance. You understand your rights related to your personal information, and that your information will only be shared as necessary to determine eligibility for services or programs, in accordance with our Privacy Policy, and as required by law.
Client Name*
Legal First and Last Name
Client Date of Birth*

MonthDayYear
Authorized Representative

First NameLast Name
Authority of Representative to sign on behalf of the Client

ParentLegal GuardianCourt OrderOther
Signature of Client or Representative Authorized by Law*

Clear
Date Signed*

MonthDayYear
Client Name

First NameLast Name

King County Homeless Management Information System (HMIS)

CLIENT CONSENT FOR DATA COLLECTION AND RELEASE OF INFORMATION
What is the HMIS?
The HMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the HMIS for King County. The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).

What is the purpose of this form?
With this form, you can give permission to have information about you collected and shared with partner agencies that help King County provide housing and services. A current list of Partner Agencies can be found at http://kingcounty.hmis.cc/participating-agencies/

DO NOT AGREE TO HAVE YOUR PERSONAL IDENTIFYING INFORMATION COLLECTED IF:
- Currently Fleeing or in danger from domestic violence, dating violence, sexual assault, or stalking.
- Receiving Services from a Domestic Violence Agency or Agencies
- Receiving Services from a Program that Requires the Disclosure of HIV/AIDS Status (i.e., HOPWA)
- Under 13 with no Parent or Guardian Available to Consent to Enter the Minor’s Information into HMIS
BY SIGNING THIS FORM, I AUTHORIZE King County and Bitfocus to share HMIS information with Partner Agencies. The HMIS information shared will be used to help me get housing and services. It will also be used to better understand and improve housing and homeless service programs. I understand that the Partner Agencies may change over time.

The information to be collected and shared includes:
- Name,birthday, gender, race, ethnicity, social security number, phone number, address
- Basic medical, mental health, substance use, and daily living information
- Housing Information
- Use of crisis services, hospitals and jail
- Employment,income, insurance and benefits information
- Services provided by Partner Agencies
- Results from assessments
- My photograph or other likeness (if included)
BY SIGNING THIS FORM, I UNDERSTAND THAT:
- King County, Bitfocus and Partner Agencies will keep my HMIS information private using strict privacy policies. I have the right to review their privacy policies.
- There is a small risk of a security breach, and someone might obtain my information and use it inappropriately.
- If I have questions about my privacy rights, my HMIS information, or am concerned that my information has been misused, I can contact my HMIS systems administrator at (206) 444-4001 x2.
- I can receive a copy of this Consent and the Client Information Sheet
- I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.
- This Consent will expire 7 years from my last HMIS recorded activity.
- I may revoke this Consent at any time in writing to:
Bitfocus, Inc.
ATTN: King County HMIS
5940 S Rainbow Blvd Ste 400 #60866, Las Vegas, Nevada 89118-2507
- The revocation will take effect upon receipt, except to the extent others have already acted under this Consent, and after Partner Agencies and King County have been notified so that revocation does not interfere with care or service coordination.
- My HMIS information may be further shared by the Partner Agencies to other agencies for care coordination, counseling, food, utility assistance, and other services.
- My HMIS information may be viewed by auditors or funders who review work of the Partner Agencies, including HUD, the Department of Veteran Affairs, the Department of Health and Human Services, and the Washington State Department of Commerce. I understand that the list of auditors and funders may change over time.
- My HMIS information may be used to help evaluate the quality of services provided. It may also be used for research purposes that align with King County’s goals and mission.
IMPORTANT: Do not enter personally identifying information into HMIS for clients who are: 1) receiving services from domestic violence agencies; 2) currently fleeing or in danger from a domestic violence, dating violence, sexual assault or stalking situation; 3) are being served in a program that requires disclosure of HIV/AIDS status (i.e.; HOPWA); or 4) under 13 with no parent or guardian available to consent to enter the minor’s information in HMIS.
Client Name*
Legal First and Last Name
Client Date of Birth*

MonthDayYear
Authorized Representative

First NameLast Name
Authority of Representative to sign on behalf of the Client

ParentLegal GuardianCourt OrderOther
Signature of Client or Representative Authorized by Law

Clear
Date Signed*

MonthDayYear
For Agency Use Only (to be kept on file at agency):
(Staff/Agency Initials)
Verify that you are human*
Client Name

First NameLast Name
Partner Organization Name (If Applicable)
Case Manager Name
Please contact us after submitting this form at 206-880-1777 to add your name.
You may NOT submit this form until the Client Name error at the top of the first page is fixed.
Should be Empty:

Client Enrollment Form

ERROR: Please correct "Client Name" above.

Health Need and Risk Factor Questionnaire

Income and Employment Questionnaire

Consent to Enroll

Authorization to Disclose, Release and/or Obtain Protected Health Information

King County Homeless Management Information System (HMIS)