Release of Information

Before discussing your case with other organizations, your permission is required. Please read the following before signing.

Why do we collect information about you?

To coordinate services with other agencies
To connect you with other helping agencies where you may be eligible for other benefits.
Sharing information can reduce the time it takes to serve you and reduce the number of times you have to tell your story.
To protect your privacy and to protect our organization.

Last 4 digits of Social Security

Are you a veteran?

Yes No

Are you currently homeless?

Yes No

Are you residing with a friend, family member, or someone else?

Yes No

Are you currently living in a vehicle, camper, or tent?

Yes No

To help you secure permanent housing, please identify any evictions you have had by year and city.

If there are others with you, please share their names and ages.

Source(s) of Income

Amount Received Monthly

Your privacy is important. Please review and initial the box next to each statement. If you have questions or concerns, please share them before checking the box.

I authorize AHS to share my information

I understand that the confidentiality of my records is protected by law. I understand that this agency will never give information about me to anyone outside the agency without my specific written consent as required by law, including the Federal Law of Confidentiality for Alcohol and Drug Abuse Patients, (42 CFR, Part 2), the Health Insurance Portability and Accountability Act of 1996 (HIPAA, 45 CFR, Parts 160 & 164 as revised by the Health Information Technology for Economic and Clinical Health Act of 2009 aka the HITECH Act), and certain Michigan laws. *

I can withdraw my consent to share at any time, but any information already shared with another agency cannot be taken back.

I understand that agencies I consent to have information shared with must follow strict privacy guidelines.

I understand that my written consent allows the information provided to be shared among agencies below.

I understand that I will not be denied services (emergency assistance, outreach, shelter, housing assistance, etc.) if I do not consent to share information.

I give my permission for ONE of the following:

To have my photo taken for use in reports, press releases, social media, etc. To have my photo (no face, taken from the back) for use in reports, press releases, social media, etc. I do not give permission to have my photo taken for use in reports, press releases, social media, etc.

I give permission to have my NAME shared in reports, press releases, marketing, social media, etc.

Yes No

I give my permission for just my initials to be shared in reports, press releases, marketing, social media, etc.

Yes No

Please note that information shared will be limited to information that is necessary and relevant to ending homelessness, stabilizing housing, and supporting health and recovery. This document is active for one year effective the date of submission.

The information in this release may be seen by and shared among the following agencies to help coordinate services.

Make Your Year-End Gift, A New Beginning for the Homeless

Release of Information

Why do we collect information about you?

Reach out to us