Healthcare Destruction Letter

HEALTHCARE DESTRUCTION LETTER

Provider Name:

Patient Information

Date of Birth:    Medical Record Number:

Phone:    Email (optional):

Records to Be Destroyed

Check each category of protected health information to be destroyed:

Medical and clinical records
Laboratory results
Imaging and radiology reports
Billing and financial records
Mental health records
Substance abuse treatment records
Other

Date range of records to be destroyed: From to

Reason for Destruction

Retention period expired (provider-initiated)
At patient request (this authorization)
Duplicate records
Other (specify)

Method of Destruction

The provider will employ reasonable, industry-standard methods to render information unreadable, irretrievable, or otherwise destroyed in a manner consistent with applicable law:

Physical shredding (paper records)
Secure electronic deletion and overwrite
De-identification in accordance with provider policy
Other (specify)

Legal Notices and Certifications

By signing below, the undersigned patient or legally authorized representative authorizes the provider to destroy the categories of protected health information identified above. The undersigned acknowledges that:

1. The provider may decline or postpone destruction if records are subject to a legal hold, pending litigation, regulatory or audit obligations, or mandatory retention requirements under applicable law. Nothing in this authorization requires the provider to destroy records that the provider is legally obligated to retain.

2. After destruction, the identified records will be irretrievable and cannot be reconstructed. The provider will not be responsible for consequences that result from the loss of records that have been lawfully destroyed in accordance with this authorization and applicable law.

3. The provider certifies that destruction will be performed using methods intended to protect the confidentiality of patient information and to prevent unauthorized access or disclosure.

4. The undersigned represents that they are the patient or the patient's legally authorized representative and have full authority to request destruction of the specified records. If signing as a representative, the representative must provide the nature of their authority below.

Revocation: This authorization may be revoked in writing at any time prior to the provider's completion of destruction. A written revocation must be delivered to the provider's main records office. Revocation will not apply to disclosures or actions taken in reliance on this authorization prior to receipt of the revocation.

Contact for Questions or Withdrawal

Phone:    Office address:

Acknowledgment and Signature

I hereby authorize the provider named above to destroy the specified records in accordance with the terms set forth herein. I have read and understand this document and acknowledge that this authorization is voluntary.

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