Healthcare Migration Signoff

HEALTHCARE MIGRATION SIGNOFF

Patient Name:    Medical Record Number:    Date of Birth:

Patient Information

Insurance Information

Migration Details

Source Organization:    Source System/EHR:

Destination Organization:    Destination System/EHR:

Migration Start Date:    Migration End Date:    Migration Reference ID:

Validation and Integrity

The receiving organization shall perform the following validation steps prior to acceptance. Confirm performed checks:

Security and Transfer

Method of transfer (check all that apply):

Security measures implemented during migration (select all confirmed):

Authorization and Acknowledgment

By signing below, I authorize the transfer and migration of my protected health information as specified above from the source organization and system to the destination organization and system. I understand and acknowledge the following:

1. Some data elements may be reformatted, combined, or truncated during migration; such changes do not alter the medical record's clinical meaning to the extent reasonably practicable.
2. The source organization will retain a backup copy of migrated records for a period consistent with its record retention policies; the destination organization assumes responsibility for records after successful acceptance.
3. I may request a review of my migrated records, and reports of known exceptions or missing items will be provided upon request to the receiving organization.
4. This authorization is voluntary and may be revoked in writing, but revocation will not affect disclosures or transfers already completed under this authorization prior to receipt of the revocation.
5. The parties involved will take reasonable administrative, technical, and physical safeguards to protect my information in accordance with applicable privacy and security requirements.

Notes / Additional Instructions

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