HomeMy WebLinkAboutachmis-roiCA-502 Oakland, Berkeley/Alameda County CoC
Updated 06/06/2025 1
Oakland–Berkeley–Alameda County Continuum of Care
Release of Information (ROI)
Authorization for Sharing Your Personally Identifiable Information
The organizations that make up Oakland–Berkeley–Alameda County Continuum
of Care (“Organizations”) are asking for your authorization to allow sharing of
your protected personally identifiable information (“information”). If you agree,
your information will be shared with (to and from) the organizations and other providers
that assist clients who are at-risk of or experiencing homelessness. This includes
providers of the following types of services:
•Homeless assistance
•Housing service
•Medical
•Behavioral health
•Related software
Sharing information makes it easier to:
•Connect you with housing programs, services, or resources.
•Coordinate your shelter, housing, or other services.
•Limit the amount of information you need to repeat.
•Improve the quality of services.
Signing this Authorization Form (“Form”) is your choice.
State and federal laws already allow for some sharing of information. Signing or not
signing this form does not change what can be shared under these laws. For example,
the organizations can collect, store, use, and share your information to:
•Provide or coordinate services.
•Collect payments.
•Run the organization.
•Create data that can’t identify you.
•Support research.
•Follow local, state, and federal laws.
•Follow court orders, respond to threats, and ensure public safety.
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By signing this Form, you authorize your information to be used or shared for
purposes in addition to those already allowed by state and federal law (shown above).
If you do not sign this Form, you do not authorize your information to be used or
shared beyond what is already allowed by state and federal law (shown above). You
can still receive some services. Not signing may keep you from being able to fully take
part in certain programs.
What information will
be shared? Information will be shared about programs and
services you got in the past, get now and in the
future. This includes data about shelter,
housing, and related needs. Information shared
may include details that may directly or
indirectly identify you, such as:
•Full name
•Home address
•Personal email address
•Social security number
•Passport number
•Driver’s license number
•Date of birth
•Telephone number
•Medical information
•Criminal history
•Photos/images
How will my information
be shared? Your information will be shared in electronic,
verbal, and written formats.
Who will be sharing my
information? Your information will be shared with (to and
from) the organizations and the types of
providers described above. This may also
include organizations involved in providing
services now, in the past, and in the future. A
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list of the Organizations and providers can
be accessed at https://alameda.bitfocus.com/
participating-organizations
How will organizations
protect my privacy? In addition to following local, state, and federal
laws, organizations will:
•Assist people who need help or translation,
as required by law.
•Explain and share their privacy notice and
privacy policy.
•Only collect the information they need.
•Have a plan for keeping information in good
order and deleting old data.
•Share the least amount of information
needed to complete a task.
•Allow you to review and correct your
information and explain if your request is
denied.
•Have a plan and train staff to handle
questions, complaints, or a data breach.
If I sign, can I change
my mind later? You have the right to change your mind about
sharing and can revoke (take back) this
authorization at any time. This form is valid for
5-10 years or until the date that you cancel or
change it in writing.
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I have the right to:
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By signing this Form I agree that:
●I have read this Form or a representative has read it to me.
●I understand it.
●I give authorization for my information to be shared as described above.
●This authorization will remain in effect for a period of 5 - 10 years, or until I
change my authorization in writing. I can do this by contacting my Housing
Provider.
Client Signature: __________________________________ Date: ____________
If signed by a person other than the client, please write that person’s name and
relationship to the client:
Representative’s Name: ________________________________________
Relationship to Client: _________________________________________
Client Name (Print):
Date of Birth:
Accompanying children:
(Under the age of 18)