Destruction Certification Form - Indiana 2025

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  1. Click ‘Get Form’ to open the Destruction Certification Form - Indiana in our editor.
  2. Begin by entering the dates of the records being filmed and referencing the appropriate retention schedule. This information is crucial for compliance.
  3. In the section for microfilm reels, provide details about the original records that have been microfilmed. Ensure accuracy as this will be part of your documentation.
  4. Carefully review each of the seven certification elements listed on the form. Confirm that all necessary documentation is available and meets the requirements outlined in Administrative Rule 6.
  5. Sign and date the form at the bottom, ensuring that it is completed by an authorized person. This signature verifies compliance with all procedures.

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A certificate of destruction or CoD is a document that states receipt and destruction of confidential data. Certificates of Destruction are issued by service providers as a statement of the completion of the destruction of electronics, documents, hard drives, and other data containing media.
Different media require different methods of destruction: shred, burn, or pulverize paper records; recycle or shred microfilm or microfiche; purge and destroy computerized records. Whatever method is used, ensure that third parties cannot discern or reconstruct patient information from destroyed records.
Paper documentation containing PHI must be shredded or placed in a secure bin. Protected Health Information must not be discarded in trash cans, unsecured recycle bins or other areas accessible by the public.
Pulverizing and pulping are especially effective for the destruction of medical records and other paper-based PHI to prevent any possibility of data reconstruction. Both methods are adequate for the destruction of protected health information contained in physical media.
(a) For paper records containing information that is confidential or exempt from disclosure, appropriate destruction methods include burning in an industrial incineration facility, pulping, pulverizing, shredding, or macerating.
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