Healthcare Certificate of Destruction

Healthcare Certificate of Destruction

Facility Information

Patient Information

Patient Name:

Date of Birth:

Phone:    Emergency Contact:

Records / Items Authorized for Destruction

Provide a detailed inventory of health information, physical records, electronic media, pharmaceuticals or other items to be destroyed. Include date ranges and identifying numbers where applicable.

Date Range: to

Date Range: to

Method and Details of Destruction

Select method(s) used to render the information irretrievable. Select all that apply and provide specifics where requested.

Cross-cut shredding (paper)

Incineration (controlled combustion)

Pulverization / Maceration

Degaussing (magnetic media)

Secure overwrite / cryptographic erasure (electronic)

Chemical destruction (pharmaceuticals or biological)

Other:

Location of Destruction:

Date of Destruction:    Time:

Third-Party or Contractor Performing Destruction

Vendor / Contractor Name:

Vendor License / Permit #:

Chain of Custody / Witnesses

Collected By (print name and title):

Transported By (print name):

Received By (vendor/onsite staff):

Witness (print name and title):

Certification and Authorization

By signing below, the undersigned authorizes the destruction of the item(s) described above and certifies that the destruction was carried out in a manner intended to prevent disclosure of protected health information to unauthorized persons. The undersigned further certifies that:

1. All items listed were under the custody or control of the Facility at the time of destruction.
2. Destruction was performed by authorized personnel or an authorized contractor using the methods indicated above.
3. A record of this Certificate of Destruction will be retained by the Facility as an administrative record of disposal.
4. The undersigned declares under penalty of applicable law that the information provided on this form is true and correct and that they are the patient or an authorized representative with authority to direct destruction.

Certification checkbox: I certify the foregoing statements are true and I authorize destruction as described.

If signed by an authorized representative, state relationship to patient:

HIPAA / Privacy Acknowledgment

The Facility affirms that destruction was completed in a manner consistent with its privacy and security obligations to protect patient health information. This Certificate documents the disposition of the records identified above and serves as evidence of destruction for audit and administrative purposes.

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