Healthcare Ashes Direction Form

HEALTHCARE ASHES DIRECTION FORM

Patient Information

Date of Birth:    Gender:

Phone:    Medical Record No.:

Relationship:    Phone:

Authorization and Direction

I, , hereby direct and authorize the healthcare facility and its authorized agents to arrange for the disposition of the cremated remains (ashes) of the patient named above in accordance with the instructions below. This direction is intended to be a legally binding statement of my wishes regarding the handling, release, and disposition of cremated remains.

Primary Authorized Recipient for Release

Relationship to Patient:    Phone:

Disposition Instructions (Select one)

Release cremated remains to the primary authorized recipient named above.
Interment at cemetery (provide cemetery name and plot information below).
Scattering of ashes (provide scattering location description below).
Retain ashes at facility pending claim (facility will hold for a maximum period as permitted by law).
Other (describe below).

Identification and Proof of Authority

I certify that I am the patient named above or that I am legally authorized to make disposition decisions on behalf of the patient. The facility may require proof of identity and legal authority prior to release. Type of identification provided at time of release:

Legal Acknowledgments, Release, and Limitations

By signing below I authorize the release and disposition of cremated remains in accordance with this direction. I understand and agree that the facility and its employees, agents, and contractors may rely on this direction and on the identification and authority of the named recipient. Upon lawful delivery of cremated remains to the authorized recipient or upon final disposition in accordance with my instructions, the facility shall have no further liability for loss, damage, or scattering or other disposition of the remains.

I release, hold harmless, and indemnify the facility and its affiliates from any claims, liabilities, or expenses arising from compliance with this direction, except for willful misconduct or gross negligence. I understand that certain dispositions (for example scattering in public places or at sea) may be subject to local, state, or federal regulations and that compliance with those regulations is my responsibility.

This direction may be revoked or amended by me in writing prior to the time the facility has acted in reliance on it. Any revocation is not effective to the extent the facility has already relied upon this direction in good faith.

Authorization Duration and Expiration

This authorization shall remain in effect until: . If no expiration is provided this authorization will be treated as indefinite until revoked in writing or until applicable law requires otherwise.

HIPAA / Privacy Acknowledgment

I acknowledge that this form authorizes disclosure of necessary protected health information to carry out the release and disposition of cremated remains as directed. I understand that information disclosed pursuant to this form may include the patient's name, date of death, medical record number, and other limited information necessary for identification and release.

Acknowledgment and Certification

I certify under penalty of perjury that the information provided here is true and correct to the best of my knowledge and that I am authorized to give these directions. I understand that falsification of information may subject me to civil or criminal penalties under applicable law.

  I certify that I have read and understand the terms above and that I am authorized to provide these directions.

Sign Now