Healthcare Destruction Form

HEALTHCARE DESTRUCTION AUTHORIZATION

I hereby authorize the destruction of my protected health information as described in this Healthcare Destruction Authorization. I understand that destruction will be performed in accordance with applicable retention schedules and privacy regulations, and that destruction may not proceed if prohibited by law, pending litigation, or a documented record hold. By signing below I attest that I am the patient or the legally authorized representative with authority to request destruction of these records.

Patient Information

Date of Birth:    Gender:

Records to be Destroyed

Check each category to be destroyed and provide additional details where required.

Medical / Clinical Progress Notes

Imaging Reports / Films

Laboratory Results

Billing / Financial Records

Mental Health Records (non-psychotherapy)

Psychotherapy Notes (requires specific authorization)

Substance Use Treatment Records (special protections apply)

HIV/AIDS Testing or Treatment Records

Date Range for Destruction: From to

Reason for Destruction

Retention period expired per organizational schedule

Duplicate or superseded records

Patient request for destruction

Administrative purge

Method of Destruction

Acceptable methods will be utilized consistent with security requirements. Select all that apply:

Secure Shredding (paper)

Secure Digital Deletion / Overwrite

Degaussing / Physical Media Destruction

Incineration

Acknowledgments and Legal Notices

By signing this document I acknowledge and authorize the destruction described above. I understand:

1. This authorization does not supersede legal or regulatory retention obligations and records subject to a legal hold, subpoena, investigation, or retained by statute may not be destroyed until the hold is lifted or retention period has expired.
2. Certain categories of records may require additional authorization or may be protected by law (for example, psychotherapy notes, substance use treatment records, HIV-related records); destruction of such records may be restricted and will be reviewed prior to destruction.
3. I may revoke this authorization in writing at any time prior to destruction; revocation will not affect actions already taken in reliance on this authorization.
4. Once destroyed, records cannot be reconstructed; destruction is irreversible.

Patient Acknowledgment: I have read and understand the notices above and authorize destruction as specified.

Records Department Use Only

Destruction completed on (date):

Method used:

Certification by Records Custodian: I certify that the information above is complete and that destruction was performed in accordance with applicable policies and procedures.

Patient Authorization and Signature

By signing below I affirm that I am the patient or am legally authorized to request destruction of the identified records. I understand the consequences described in this form and consent to the destruction indicated.

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