Data collection and release is a critical component of our community’s ability to provide the most effective services and housing possible. This Notice and Consent describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions or information regarding this form contact your provider Carson City
Human Services.

What is the CMIS and eLogic (Referred to as Systems)?
The CMIS and eLogic are data systems that stores information about homelessness services. The purpose of the these systems are to improve services that support people who are homeless or at risk of homelessness to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).

What is the purpose of the form?
With this form, you can give permission to have information about you collected and shared with Partner Agencies that help Nevada provide housing and services. By signing this form, I authorize the State of Nevada, Bitfocus and eLogic to share information with Partner Agencies. The information shared will be used to help me get housing and or other services. It will also be used to help evaluate the quality of housing and other services provided. I understand that the Partner Agencies may change over time.

The Information to be collected and shared includes:
Name, date of birth, gender, race, ethnicity, social security number, phone number, and address.
Basic medical, mental health, substance use, and daily living information.
Housing information. Use of crisis services, veteran services, hospitals and jail.
Employment, income, insurance and benefits information.
Services provided by Partner Agencies.
Results from assessments.
My photograph or other likeness (if included).

By Signing this Form, I understand that:
The Systems and Partner Agencies will keep my information private using strict privacy policies that I may request.
I can receive a copy of this Consent and the Client Information Sheet.
I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.
This Consent will expire 5-years from my last recorded activity in the databases.

I may revoke this consent earlier at any time by returning a completed Revocation of Consent form, available
at http://nvcmis.bitfocus.com, to support@bitfocus.com, and Carson City Human Services Division.
The revocation will take effect upon receipt, except to the extent others have already acted under this Consent.
My information may be viewed by auditors or funders who review work of the Partner Agencies, including HUD, The Department of Veteran Affairs, and Nevada Department of Health and Human Services. I understand that the list of auditors and funders may change over time.
My information may be shared to coordinate referral and placement for housing and other services.
My information may be further shared by Partner Agencies to other agencies for care coordination, counseling, food, utility assistance, and other services.
My information will be used to help evaluate the quality of social services.
My information may be used for research; however, my identity will remain private.

Opt Out: If you wish to opt out of having your information collected in the Systems, please sign “I do not consent”, your signature, and date.

By Signing you are verifying your signature and agreeing to the collection of information.