Skip to main content

HIPPA - Precision Computer Recycling Authorization Form

Precision Computer Recycling Authorization Form



Owner Information

Owner Full Name: ___________________________________________________________

Address: _________________________________________________________________

City/State/ZIP: ___________________________________________________________

Phone: ______________________________  Email: ______________________________

(Optional) Business/Organization Name: _____________________________________

(Optional) Authorized Signer Title: ________________________________________



Description of Items to be Recycled (attach list if needed)



[ ] Computer/Desktop  [ ] Laptop  [ ] Monitor  [ ] Printer/Copier/Scanner/Fax

[ ] Phone/Tablet  [ ] Cables/Accessories  [ ] Keyboards/Mice  [ ] Projector

[ ] Server [ ] Networking Gear  [ ] Batteries/UPS  [ ] External/Internal Hard Drives

Other (list any additional items): ________________________________________



Ownership and Authority

I, the undersigned Owner (or authorized agent of the Owner), represent and warrant that:

- I am the lawful owner of the listed items or have full legal authority to dispose of them.

- The items are free of liens or third‑party claims unless disclosed in writing.



Authorization and Transfer

I authorize Precision Computer to collect, transport, and recycle (and, where applicable, refurbish, resell, dismantle for parts, or otherwise process) the listed items in accordance with applicable laws and industry standards. I hereby transfer all right, title, and interest in the items to Precision Computer upon pickup/drop‑off. Items and components will not be returned; disposition decisions are final.



Data-Bearing Devices (HIPAA ePHI Handling)

[ ] Items may contain ePHI             [ ] Items do NOT contain ePHI            [ ] Unknown

Covered Entity/BAA Status:
- Covered Entity/Business Associate Name: __________________________________________
- BAA on file: [ ] Yes   [ ] No (execute prior to processing)

Requested Data Sanitization per NIST SP 800-88 Rev.1 (select one per device type):
[ ] Clear (logical overwrite)        Tool/Procedure: ________________________________
[ ] Purge (e.g., crypto erase, degauss)   Details: _________________________________
[ ] Destroy (physical shred/pulverize)    Target size/spec: ________________________

Certificate of Destruction requested: [ ] Yes   [ ] No
Certificate to be issued to (name/email): __________________________________________

PHI Safeguards Acknowledgment:
- Minimum necessary access will be applied; devices/media safeguarded in transit and storage (locked containers, tamper-evident seals).
- Precision Computer will implement commercially accepted methods aligned to NIST SP 800-88; deviations require written approval.

Hazardous/Prohibited Materials

I confirm the items do not contain prohibited or hazardous materials except as disclosed in writing. Precision Computer may refuse any item at its discretion.



Release and Indemnity

To the fullest extent allowed by law, I release and hold harmless Precision Computer, its employees, and agents from claims arising out of the removal, transport, processing, or recycling of the items, and I waive and disclaim any and all damages of any kind (including direct, indirect, incidental, consequential, special, exemplary, or punitive damages) arising from or related to the items after transfer, the services provided, or any disposition decisions, except to the extent caused by Precision Computer’s willful misconduct or gross negligence.



Compliance and Records

Precision Computer will handle items in compliance with applicable laws and may use certified downstream recyclers. Certificates of recycling or data destruction (if requested and offered) will be provided after processing.



Chain of Custody (Required for data-bearing devices)

Initial Custody
- Released by (print/sign/date/time): ______________________________________________
- Received by (print/sign/date/time): ______________________________________________
- Container/Seal #: __________________________   Condition: _________________________

Transfers (add rows as needed)
| Date/Time           | From (Name/Sign)                 | To (Name/Sign)                   | Purpose/Notes                      |
|_____________________|__________________________________|__________________________________|______________________|
|                     |                                  |                                  |                                    |
|                     |                                  |                                  |                                    |
|                     |                                  |                                  |                                    |

Transport/Storage Safeguards
[ ] Tamper-evident packaging used      [ ] Locked vehicle/container      [ ] Secure on-site cabinet
[ ] Background-checked personnel       [ ] Approved downstream vendor     [ ] BAA in place (if applicable)

Signatures

Owner/Authorized Agent (print): ____________________________________________

Signature: ....................................................................    Date: ___/___/____



If signing for a business, Title: ___________________________________________

Accepted by Precision Computer Representative (print): _________________

Signature: ....................................................................    Date: ___/___/____


Back to top