CAS-700 (E) 06/24/2021
NYC Human Resources Administration HIPAA Compliant Consent for the Coordinated
Assessment Survey and/or Supportive Housing Application
Client Name _________________________________________________________________
Date of Birth ___________________________________ SS #________________________
Organization Assisting Client _____________________________________________________
We need your SS# to assess your eligibility for supportive and/or affordable housing under federal
law (42 U.S.C. § 1437, 42 U.S.C. § 2000d, 42 U.S.C. § 3601-19, and 42 U.S.C. § 3543).
By signing this consent, you agree to let the Human Resources Administration (HRA) use and share
your confidential health information to help you obtain appropriate housing placement. Your
information will be shared between HRA, the Organization listed above that is helping you, and
organizations listed in Attachment A.
Your confidential health information includes:
• Your health information entered into the Coordinated Assessment Survey and the
Supportive Housing Application systems. This includes any prior surveys or applications
from the past ten (10) years.
• Your Medicaid records and health information including medical, mental health, HIV-related,
and alcohol and substance abuse use records.
HRA will use this information to determine your eligibility for and complete your applications for
supportive housing and other related housing programs.
We may share your confidential health information with the organizations listed in Attachment A for
purposes related to referral, placement, evaluation, and tracking. We will only share your information
with the organizations that are related to the housing types and rental subsidies that you may qualify
for. These organizations may re-share your confidential health information to the housing and
subsidy providers that you may be referred to.
Before Signing, You Should Know:
• You must sign this consent to apply for supportive housing. If you do not sign, your
treatment, payment, enrollment in a health plan, or eligibility for non-Supportive Housing
benefits will not be affected.
• Your health information is protected by the Privacy Rule of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
• Your confidential information may be re-released by HRA or the other organizations listed in
Attachment A. The privacy of this information may no longer be protected by federal or
state law.
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CAS-700 (E) 06/24/2021
• You can ask for a list of people who may get or use your HIV-related information without your
consent. If you suffer discrimination because of the release of HIV-related information, you
may contact the New York State Division of Human Rights at (212) 961-8650 or the New
York City Commission on Human Rights at (212) 306-7450. They are in charge of protecting
your rights
• You will be given a copy of this consent.
• After signing this consent, you can change your mind at any time and cancel your consent.
However, HRA may have already shared your information based on your consent.
• To cancel your consent, please send a letter to: Placement Assessment and Client Tracking
Unit, Customized Assistance Services, Human Resource Administration, 150 Greenwich
Street, 30th Floor, New York, NY 10007.
• This consent will end fifteen (15) years after the date that you sign this consent.
By signing this consent, you agree to the use and sharing of your confidential information as described above.
You may ask questions about anything you do not understand.
_____________________________________________
Name (Print)
_____________________________________________ ________________________
Signature of Client of Person Authorized to Consent Date
Basis of Authority to Sign on Behalf of Client: __________________________________________
2
CAS-701 (E) 06/24/2021
NYC Human Resources Administration Consent for the Coordinated Assessment Survey
and/or Supportive Housing Application
Client Name _________________________________________________________________
Date of Birth _____________________________ SS # ____________________________
Organization Assisting Client ____________________________________________________
We need your SS# to assess your eligibility for supportive and/or affordable housing under federal
law (42 U.S.C. § 1437, 42 U.S.C. § 2000d, 42 U.S.C. § 3601-19, and 42 U.S.C. § 3543).
By signing this consent, you agree to let the Human Resources Administration (HRA) use and share
your confidential information to help you obtain appropriate housing placement. Your information
will be shared between HRA, the Organization listed above that is helping you, and organizations
listed in Attachment A.
Your confidential information includes:
• Your information entered into the Coordinated Assessment Survey and the Supportive
Housing Application systems. This includes any prior surveys or applications from the
past ten (10) years.
• Your other applicable HRA records including but not limited to: Cash Assistance;
Supplemental Nutrition Assistance Program (SNAP); Domestic Violence shelter stay; and
Adult Protective Services (APS).
HRA will use this information to determine your eligibility for and complete your applications for
supportive housing and other related housing programs.
We may share your confidential information with the organizations listed in Attachment A for
purposes related to referral, placement, evaluation, and tracking. We will only share your
information with the organizations that are related to the housing types and rental subsidies that
you may qualify for. These organizations may re-share your confidential information to the housing
and subsidy providers that you may be referred to.
Before Signing, You Should Know:
• You must sign this consent to apply for supportive housing. Your eligibility for other HRA
benefits and services will not be affected if you do not sign.
• If you sign this consent, you may ask for a copy of this form. We will give it to you.
• After signing this consent, you can change your mind at any time and cancel your consent.
However, HRA may have already shared your information based on your consent.
• To cancel your consent, please send a letter to: Placement Assessment and Client Tracking
Unit, Customized Assistance Services, Human Resource Administration, 150 Greenwich
Street, 30th Floor, New York, NY 10007.
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CAS-701 (E) 06/24/2021
• This consent will end fifteen (15) years after the date that you sign this consent.
By signing this consent, you agree to the use and sharing of your confidential information as described above.
You may ask questions about anything you do not understand.
_____________________________________________
Name (Print)
_____________________________________________ ________________________
Signature of Client of Person Authorized to Consent Date
Basis of Authority to Sign on Behalf of Client: __________________________________________
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Attachment A (E) 07/31/2024
Attachment A
By signing the attached consents CAS-700 (E) and CAS-701(E), your information may be
shared with the following organizations:
• NYC Administration for Children's Services (ACS)
• NYC Center for Innovation through Data Intelligence (CIDI)
• NYC Department of Correction (NYC DOC)
• NYC Department of Health and Mental Hygiene (DOHMH)
• NYC Department of Homeless Services (DHS)
• NYC Department of Probation (NYC DOP)
• NYC Department of Social Services (DSS)
• NYC Department of Veterans' Services (DVS)
• NYC Department of Youth and Community Development (DYCD)
• NYC Health + Hospitals (H + H)
• NYC Housing Authority (NYCHA)
• NYC Housing Preservation and Development (HPD)
• NYC Human Resources Administration (HRA)
• NYC Mayor’s Office to End Domestic and Gender-Based Violence (ENDGBV)
• NYS Department of Health (DOH)
• NYS Division of Criminal Justice Services (DCJS)
• NYS Division of Parole (DOP)
• NYC Homes and Community Renewal (HCR)
• NYS Office of Alcoholism and Substance Abuse Services (OASAS)
• NYS Office of Children and Family Services (OCFS)
• NYS Office of Mental Health (SOMH)
• Institute for Health System Evaluation (IHSE)
• State University of New York (SUNY)
• The Center for Urban Community Services (CUCS)
• The National Center for Addiction and Substance Abuse (CASA)
• University of Albany – Center for Human Services Research (CHSR)
• U.S. Department of Housing and Urban Development (HUD)
• U.S. Department of Veterans Affairs (VA)
Note: While we are providing you with the most up-to-date list, HRA may add or remove
organizations over time.
