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HMIS Client Revocation Of Consent Form – Updated 6/7/2018 (PDF).pdf

hau-hmis-consent-revocation-form-2018.pdf

Preview of HMIS Client Revocation of Consent Form – Updated 6/7/2018 (PDF)

🔗 Source: commerce.wa.gov

📊 Size: 124 KB

👤 Author: talias

⬇️ Downloads: 108

Summary

Client Revocation of Consent form allows clients to revoke permission for an agency to enter personally identifying information into the Washington State Homeless Management Information System (HMIS). The client can choose to revoke consent for one agency or all agencies in the Washington HMIS. Upon revocation, personally identifying information such as name, social security number, birthdate, and contact information will be removed from HMIS, while non-identifying information will remain. The client's decision does not affect their receipt of services from the agency. The form requires client signature, print name, and date, as well as agency witness signature, print name, and date.

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Description

Client Revocation of Consent form allows clients to revoke permission for an agency to enter personally identifying information into the Washington State...

Technical Information

File Format: PDF
File Size: 124 KB
Pages: 1
Language: EN
Author: talias
Total Downloads: 108
Last Updated: 1 month ago

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HMIS Client Revocation Of Consent Form – Updated 6/7/2018 (PDF).pdf

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