Healthcare Cremains Form

HEALTHCARE CREMAINS FORM

Decedent / Patient Information

Date of Birth:    Date of Death:    Gender:

Authorized Representative / Requestor

Phone:    Email:

Next of kin    Executor / Personal Representative    Power of Attorney (post-mortem authorization)    Other (describe below)

Crematory / Funeral Home / Recipient

Recipient Relationship:

Disposition Instructions

Select desired disposition action (check one or more as applicable):

Release full cremains to named recipient above
Transfer to funeral home/crematory listed above for processing/transport
Retain cremains at facility for pickup (number of days authorized: )
Authorized scattering or memorial disposition (describe location)

Transfer, Transport, and Shipping

Method of transfer (check applicable):

Personal pickup by authorized representative
Transport by facility to funeral home listed above
Ship via authorized carrier (recipient acknowledges additional shipping fees and liability)

Fees, Storage, and Hold Harmless

I acknowledge that any applicable fees for cremation, storage, handling, or shipping are my responsibility and must be paid prior to release. The facility's storage policy provides for final disposition or disposal of unclaimed cremains after the period specified under facility policy; I accept responsibility for timely collection.

I acknowledge responsibility for fees and storage policy.

Authorization and Release

By signing below, I certify under penalty of law that I am the person legally authorized to direct disposition of the decedent's cremated remains. I authorize the healthcare facility and its agents and contractors to release and transfer the cremains in accordance with these instructions. I understand and accept that once cremains are released to the named recipient or shipped, the facility is not responsible for subsequent loss, damage, commingling, or dispersal.

I agree to indemnify and hold the facility harmless from any claims, demands, or liabilities that may arise from honoring this authorization, including claims by other potential heirs unless I provide legal documentation superseding my authority.

Privacy / HIPAA Acknowledgment

I authorize the facility to disclose decedent identification information and limited protected health information necessary to complete disposition and transport of cremains to the recipient named in this form. This authorization is limited to the purposes stated and will expire on the date indicated below unless revoked in writing earlier.

Additional Declarations

I certify that the statements made in this form are true and correct to the best of my knowledge. I further certify that I will provide copies of any legal documents required to verify my authority if requested by the facility.

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