Participant/ Head of Household Name:	Click or tap here to enter text.

This Release of Information (ROI) allows agencies participating in the Homeless Interagency Solutions Team (HIST) to discuss your circumstances and determine suitability for available health and housing services.

The goal of this team is to help individuals move out of homelessness through targeted services and care coordination from multiple county agencies. Completion of this document authorizes a representative of the Sacramento County HIST to obtain information related to services and supports you may receiving from various County programs to more effectively support you and address your needs.

The following information will be shared with agencies that participate in the HIST, as needed, to help participants find appropriate housing and supportive services. This information may include, but is not limited to, the following:

Age Gender Veteran status Disability status Last permanent address Income Demographics Homeless History	Past or present mental health information, difficulties or diagnoses Past or present physical health problems Past or present challenges with social supports Past or present interactions with first responders Past or present substance abuse challenges or diagnoses (including alcohol and drug treatment records) Past of present history with Child Protective Services or Adult protective Services

The list of agencies participating in HIST can change over time and the current list is comprised of team members from the following department and/or agencies: Sacramento County Department of Homeless Services and Housing, Human Assistance, Behavioral Health, Probation, Public Health, Department of Child, Family and Adult Services, Public Defender’s Office and the Housing Authority.

You may limit how this information is shared in the manner provided below. Please initial next to ONE selection:

You are authorized to share my name and information to the HIST
You are NOT authorized to share my name, but you are authorized to use a case number or other anonymous identifier. You may share my information to the HIST.
I do NOT authorize you to share my name or information, and I choose not to participate in HIST. I understand without access to my information, I will not be considered for housing openings, referrals or linkages to housing services.

RIGHT TO REVOKE

*I understand I have the right to revoke this ROI at any time by submitting a written revocation to an Agency participating in HIST. I understand the revocation will not apply to information that has already been released in response to this authorization.

* I understand if I refuse to sign this ROI or later revoke it, my refusal will not affect my ability to obtain treatment with the participating agency. My refusal will only impact my ability to have my case considered for HIST.

*I understand that I may, upon request, inspect the information to be disclosed under this ROI.

*I understand that once information is released as specified under this authorization, the participating agency cannot prevent re-disclosure of that information. However, I understand that Agencies participating in HIST keep information protected in a confidential environment and no unauthorized third party will be allowed to attend meetings in which information is disclosed.

By signing below, you agree that:

You’ve read through this form, or had someone read it to you.

You’ve been given the opportunity to ask questions, and understand the answers.

You agree to share information as outlined above.

Name of Participant or Legally Responsible Party (print full name):	Enter text	DOB:	MM/DD/YY
Participant or Legally Responsible Party signature:	Date:	MM/DD/YY
If Legally Responsible Party, relationship to Participant:	Enter text
Agency Representative, Name and Agency :	Enter text
Agency Representative (print full name):	Enter text	Date:	MM/DD/YY

EXPIRATION OF AUTHORIZATION

This Authorization for Release of Information shall expire on the following date, event or condition: Unless a different date is otherwise specified above, this consent expires in five (5) years after the date of signature, if not previously revoked.

*I understand if I am signing as a Legally Responsible party for a minor under the age 18, this authorization will expire upon the participant reaching the age of 18. Unless otherwise under the legal guardianship of the legally responsible party, the 18 year old participant will need to sign a new authorization in their name.

ADDITIONAL HOUSEHOLD MEMBERS

The Legally Responsible Party, is signing for the release of information for the following household members who are under 18 years of age:

Full Name, print:	Enter text	DOB:	MM/DD/YY
Full Name, print:	Enter text	DOB:	MM/DD/YY
Full Name, print:	Enter text	DOB:	MM/DD/YY
Full Name, print:	Enter text	DOB:	MM/DD/YY
Full Name, print:	Enter text	DOB:	MM/DD/YY
Full Name, print:	Enter text	DOB:	MM/DD/YY

Note: Household members 18 years of age or older must sign an ROI to release their information.