Clarity Agency Set-Up Form

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Clarity Agency Set-Up Form

This form should be completed by an organization that is interested in joining Rhode Island HMIS only after the successful submission of a Partnership Agreement and, if applicable, a Business Agreement (for HIPPA covered entities).

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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

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This form was created inside of Rhode Island Coalition to End Homelessness. Report Abuse