Fillable For Atmos Energy Customers Only CLIENT CONSENT AND

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For Atmos Energy Customers Only CLIENT CONSENT AND

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MAACLink is a computer system that is used locally as a Homeless Management Information
System (HMIS). Use of an HMIS is required by the US Department o
f Housing and Urban
Development (HUD) for agencies that receive HUD funding. MAACLink is not electronically
connected to HUD and is only used by authorized agencies. All MAACLink users have re-
ceived confidentiality training and have signed strict agreements to protect clients’ personal
information and limit its use appropriately.
A Privacy Notice is available at participating agencies. It provides details on how member
agencies and their employees handle client information and data sharing.
I give permission to OPPORTUNITIES FOR WILLIAMSON & BURNET COUNTIES to collect
and enter my personal and household information into the MAACLink computer system.
I understand that the MAACLink system is shared with and used by authorized agencies
in my community for the purposes of:
1. Assessing the needs of low-income, homeless or other special-needs people in
order to give better assistance and to improve their current or future situations.
2. Improving the quality of care and service for people in need.
3. Tracking the effectiveness of community efforts to meet the needs of people who
have received assistance.
4. Reporting data on an aggregate level that does not identify specific people or their
personal information.
I understand that:
· Information I give about my physical or mental health will NOT be shared outside
the agency I am working with.
· I have the right to view my MAACLink file with an authorized user.
· Signing this release form does not guarantee that I will receive assistance.
· I may revoke my authorization by completing a revocation form.
· All agencies that use MAACLink will treat my information with respect and in a pro-
fessional and confidential manner.
· Unauthorized people or organizations cannot gain access to my information withou
t
m
y consent.
· If I receive services from Homeless Prevention Rapid Re-Housing Federal S
timulus
(H
PRP) Funds, my information may be viewed by other participating agen
cies
a
cross Continuums of Care.
Agency Representative Signature
Client Signature
Client Name (Printed)
Agency Representative Name (Printed)
CLIENT CONSENT AND
RELEASE OF INFORMATION
For Atmos Energy Customers Only
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For Atmos Energy Customers Only CLIENT CONSENT AND

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Completed 4 January 2021

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