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HMIS Agency Set-Up Form
To be filled out by an organization that is interested in joining Rhode Island HMIS.
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* Indicates required question
Agency Name
*
Your answer
Is your organization a nonprofit, 501(c)3 organization?
*
Yes
No
Is your organization a HIPAA covered entity?
*
Yes
No
Please explain the overall mission of your organization and how you work with those at-risk or experiencing homelessness.
*
Your answer
Name of Person Requesting HMIS Access
*
Your answer
Email Address
*
Your answer
Title
*
Your answer
Phone Number
*
Your answer
Main Address of your Facility, including city, state and zip code (if scattered, please list the address where most of your project is located
*
Your answer
If the mailing address for your agency is different than the address listed above, please list the full mailing address here. Otherwise, you may skip thiis question.
Your answer
Who is the main point of contact for this agency in HMIS and what is their title?
*
Your answer
What is their email address?
*
Your answer
What is their phone number?
*
Your answer
If there are other point(s) of contact for your organization, please list their full information here.
*
Your answer
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