Laserfiche WebLink
Attachment 4: Certification of Destruction/Disposal of Confidential lnformation <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:tr DtsposED oF/DEsrRoyED ALL coptEs <br />You cenify 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 lnformation Disposed of/ Destroyed <br />Date of Destruction <br />Method(s) of destroying/disposing of Confidential lnformation <br />Disposed ofiDestroyed by: <br />S nature Date <br />Printed Name: <br />Title: <br />HCA Contract No Page 1 of25