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The document outlines the Client Consent to Data Collection and Release of Information for the Santa Clara County Homeless Management Information System (SCC HMIS). It details how client information related to homelessness is collected, used, and shared among partner agencies to improve services. Clients must consent to this data collection, which includes personal and health information, while being assured of confidentiality protections. The document also explains clients' rights regarding their information, including the ability to revoke consent.

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Click ‘Get Form’ to open it in the editor.
Begin by reviewing the introductory section carefully, which outlines how your information will be used and shared. This ensures you understand the purpose of the consent.
In the authorization section, initial next to each type of protected personal information (PPI) or protected health information (PHI) you consent to share. Make sure to check all relevant boxes.
Fill in any required fields, including your name and date. Ensure that all initials are present where necessary, as missing initials may invalidate your consent.
Sign electronically at the designated area. Remember that your electronic signature holds the same legal weight as a handwritten one.
Review all entries for accuracy before submitting. Once satisfied, click ‘Submit’ to finalize your consent.

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