Healthcare Archival Certificate

HEALTHCARE ARCHIVAL CERTIFICATE

Facility Name:   Custodian of Records:

Patient Information

Record Identification and Scope

Description of records archived (summary of contents and media):

Types of records included:
Progress notes    Imaging/studies    Laboratory results    Operative reports
Billing/administrative    Consents    Other:

Archival Action and Custodian Certification

Archival Date: . The undersigned Custodian of Records certifies that the records described above have been transferred to archival storage under the facility's authorized retention policy and in a manner intended to preserve authenticity, integrity, and retrievability.

Method of archival (select all applicable):
Digital imaging/electronic record    Microfilm    Paper physical archive    Hybrid (mixed media)

Access restrictions: Restricted to authorized personnel only    Released only by court order or subpoena    No additional restrictions beyond standard privacy protections

Patient Acknowledgment and Authorization

By signing below, I, the Patient named above (or the patient's legally authorized representative), acknowledge and authorize the archival of my protected health information as described in this certificate. I understand that archived records will be retained, secured, and made available in accordance with applicable law and facility policy. I understand that I may request access to my archived records and that I may revoke this authorization in writing except to the extent action has already been taken in reliance on this authorization. This authorization will expire on the date indicated below or upon earlier revocation according to facility procedures.

Authorization expiration date:

HIPAA privacy acknowledgment: I acknowledge I have received or been offered the facility's notice of privacy practices governing protected health information.

Warning: Any person who knowingly makes a false statement or conceals a material fact on this certificate may be subject to criminal or civil penalties under applicable law.

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