HOSPITAL/CLINIC RECORDS DESTRUCTION 
		        FAX NOTIFICATION FORM

TO:	 	DEPARTMENT OF PUBLIC HEALTH
	 	DIVISION OF HEALTH CARE QUALITY – ATTENTION:  INTAKE UNIT
	 	FAX NUMBER: 617-753-8165

FROM: 	Hospital/Clinic Name:	__________________________________________
	
		Address (Street):	__________________________________________
	
		Address (City/Town)	__________________________________________

In accordance with 105 CMR 130.370(F) or 105 CMR 140.302(F), this is to notify the Department that, no sooner than 30 days from the date of notification, the following medical records will be destroyed:

Type of records:           __________________________________________________________________

Date range of records: __________________________________________________________________

Date(s) of destruction:	__________________________________________________________________

As the authorized representative of the above hospital/clinic, I certify that all records to be destroyed exceed the 20 year retention period, and that the hospital/clinic and its agents and contractors will ensure that the confidentiality of medical and personal information is maintained throughout the destruction process.

______________________________________________________		________________________
Signature of Authorized Representative					Date  	

Name:   ___________________________________________

Title:      ___________________________________________

Email:    ___________________________________________

Phone:   (________)__________-___________Ext:_________

Additional Comments:

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