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Attachment 4: Certification of Destruction/Disposal of Confidential Information <br />(To Be Filled Out and Returned to HCA Upon Termination of DSA) <br />NAME OF CONTRACTOR: DATA SHARE AGREEMENT (DSA) #: <br />(Contractor) herby certifies that the data elements listed below or attached, <br />received as a part of the data provided in accordance with DSA have been: <br />❑ DISPOSED OF/DESTROYED ALL COPIES <br />You certify that you returned or destroyed all identified confidential information received from HCA, or created, <br />maintained, or received by you on behalf of HCA. You certify that you did not retain any copies of the confidential <br />information received by HCA. <br />Description of Information Disposed of/ Destroyed <br />Date of Destruction: <br />Method(s) of destroying/disposing of Confidential Information: <br />Disposed of/Destroyed by: <br />Signature Date <br />Printed Name: <br />Title: <br />HCA Contract No. Page 1 of 25 <br />