Client Consent To Data Collection And ROI - Santa Clara County ... - scc hmis 2026

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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 and housing quality. Clients must consent to the collection and sharing of their personal and health information, which is protected under various confidentiality regulations. 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, 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) and protected health information (PHI) that you consent to share. This includes identifying information, medical records, and financial details.
Fill in the expiration date for your consent at the designated space. Ensure this is completed as it is crucial for the validity of your consent.
Sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship to you.

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Versions	Form popularity	Fillable & printable
2021	4.7 Satisfied (32 Votes)
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2015	4.3 Satisfied (61 Votes)

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