HMIS Agency Agreements and Client Consent Forms

The Homeless Missourians Information System (HMIS) Steering Committee has developed a set of four operating forms for your agency’s use with the HMIS database. The forms are required to be used by all participating agencies, and are described below (Adobe Acrobat Reader is required... click here to get the FREE Adobe Acrobat Reader).

To see and print each form, click on the title of the form. These forms can also be obtained from MASW by contacting via email Roxanne Parker, Project Coordinator (Regions 1, 6, 7, 8 & 9) or Lindsay Wallace, Project Coordinator (Regions 2, 3, 4, 5 & 10) or by calling 573-632-2567.

These forms are updated periodically. If you are a participating partner agency, your agency will be notified by email when an updated version of any form is available.

Agency Partner Agreement (Revised May 2009)

This form is an agreement between your agency and the Missouri Association for Social Welfare (MASW), the agency that received the grant from HUD to create the HMIS. The form describes our mutual responsibilities in connection with the use of the HMIS database. It spells out many of the duties of the partner agency as a whole toward maintaining the confidentiality of client information. The Executive Director of your agency, or a person with similar responsibility, should read and sign this form. The original, signed in blue ink, form must be returned to MASW before your agency will be granted access to the HMIS database. You may mail the form to MASW, Attention: HMIS, 606 East Capitol Avenue, Jefferson City, 65101.

User Policy, Responsibility Statement & Code of Ethics (Revised March.2010)

The process for getting a user enrolled to use the HMIS has changed. A document explaining the process is now available for download . Each person that your agency wishes to designate as a User of the HMIS database must fill this form out and sign it. The form describes the duties of HMIS users in keeping client information confidential and maintaining the security of the HMIS database. The original, signed in blue ink, form(s) must be returned to MASW before your agency will be granted access to the HMIS database. Please mail the form(s) to MASW, Attention: HMIS, 606 East Capitol Avenue, Jefferson City, MO 65101.

Client Consent—Release of Information (Revised Jan 2004)

Every client your agency serves must read, understand, and sign this form before your agency may enter his or her information in the HMIS database. The purpose of the form is to ensure that all clients understand why they are being asked for the information collected in HMIS, and what it will be used for. When you serve multiple clients within the same family or household, the head of the household signs and gives consent on behalf of the other members of that household. Please photocopy this form and keep a supply on hand. A copy of the HMIS Computer Reuse and Disposal Policy is now available for download.

List of HMIS Partner Agencies (Updated July 2010)

The Client Consent—Release of Information form notifies all clients that they have the right to review a list of all the partner agencies that participate in the HMIS prior to signing the Client Consent form. If a client asks to see the list of partner agencies, you may click the above link and display this information to the client, or print out a list and give it to the client. This list is subject to frequent updates, so be sure to check this site for the latest list available.

Client Revocation of Consent to Release Information

Should a client wish to revoke his or her consent to share their information in the HMIS database, the Client must sign this form. The agency Staff person assisting the client must also sign the form and immediately notify the agency of the revocation. The agency must then notify the System Administrator (Sandy Wilson, MASW) of the revocation. Revocation means that the Client’s information is rendered invisible to all users in the database; the information remains for purposes of aggregate reporting only.

Blind Agency Privacy & Confidentiality Sign (Revised Aug 2005)

Agency Privacy & Confidentiality Sign (Revised Aug 2005)

Entering for ESG? Be sure to check out the ESG tips sheets, to make sure you've got your categories set up correctly!

ESG Tip Sheet (Part 1)

ESG Tip Sheet (Part 2)

Helpful Tools

HUD's Newest Technical Data Standards - March 2010
Sample ROSIE Intake Form (WORD)
Sample Privacy Notice (WORD)
Sample Privacy Notice Summary (WORD)
Sample Grievance Policy (WORD)
Tip Sheets

Updated: 11/20/2008