Healthcare Burial Grant Application

Healthcare Burial Grant Application

Use this application to request a burial or cremation grant administered by the healthcare facility or program. Complete all applicable sections, attest to the accuracy of the information under penalty of perjury, and provide required documentation as indicated. Incomplete applications may be delayed or denied.

Decedent Information

Date of birth:    Date of death:

Applicant / Authorized Representative Information

Applicant date of birth:    Phone:

Are you the legal representative, executor, or next-of-kin with authority to arrange disposition?   Yes    No

Funeral / Disposition Provider

Burial    Cremation    Other:

Itemized Estimated Costs and Grant Request

Basic services and administrative fees:
Casket, urn, or container:
Transportation and preparation:
Burial plot / cremation fee / interment:
Other (describe):

Insurance, Benefits, and Other Resources

Yes    No

Financial Information (for eligibility review)

Required Attachments Checklist

Check each document you are submitting with this application (photocopies acceptable where allowed):
Death certificate provided
Funeral contract or estimate provided
Applicant photo ID provided
Proof of relationship or authority provided (e.g., will, letters)
Proof of income or financial hardship provided

Authorization, Certifications, and Privacy Acknowledgment

I certify that the information provided in this application is true and correct to the best of my knowledge. I understand that knowingly providing false information may subject me to civil or criminal penalties and may require repayment of grant funds disbursed in error.

I authorize the release of necessary medical and administrative records to the reviewing authority for the limited purpose of verifying decedent identity, date of death, and eligibility for burial grant assistance. This authorization includes release of records relating to the decedent's inpatient admission and disposition. This authorization expires on:

Privacy acknowledgment: The applicant acknowledges that records obtained under this authorization are protected by applicable privacy laws and will be used only to determine eligibility and process this application. Unlawful disclosure of protected health information is subject to penalties under state and federal law.

I understand that if funds are awarded, the grant will be disbursed to the funeral provider unless otherwise authorized in writing, and that the awarding entity may require invoices, receipts, or proof of payment. I further understand that any unused funds must be returned and that fraudulent use of funds is grounds for recovery and legal action.

Applicant acknowledgment: I certify the above and consent to the necessary release and verification of records.

Additional Information

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