Healthcare Cremation Paperwork

Healthcare Cremation Authorization and Release

Facility Name:

Decedent Information

Date of Birth:

Authorizing Agent / Contact

Insurance and Medical Background

Cremation Authorization

I, the undersigned Authorizing Agent, hereby authorize the named facility and its agents to cremate the remains of the decedent named above. I certify that I am legally authorized to make disposition decisions for the decedent under applicable law and that no other person with superior legal right to authorize cremation is known to me. I understand cremation is irreversible and that identification of remains prior to cremation must be completed.

Decedent Name Confirmed:

Permit Number (if issued):

Individual (single remains exclusively processed)
Communal (remains may be commingled; not returnable)
Individual with minimum identification procedures as performed by facility

I affirm that the pacemaker or other pressurized implanted device has been removed by qualified personnel prior to cremation.

Disposition of Cremated Remains

Return of remains to Funeral Home or Agent: Return to funeral home / agent
Scatter remains (provide instructions below)
Bury cremated remains (provide cemetery and plot information below)
Other (specify below)

Acknowledgements, Representations and Releases

By signing below I represent and warrant that I have the legal authority to authorize cremation and to direct disposition of the decedent's remains. I release, discharge and hold harmless the facility, its employees, agents and contractors from any and all claims, liabilities, suits or demands arising out of or relating to the cremation and disposition, except for willful misconduct. I acknowledge that the facility will exercise reasonable care in the handling and cremation of remains, and that cremation may permanently alter or destroy medical implants, prosthetics and identifying features.

I authorize the facility to take and retain photographs, x-rays or records as necessary for identification, regulatory compliance and recordkeeping related to cremation and disposition.

HIPAA / Privacy Acknowledgment and Limited Authorization

I acknowledge that certain health information about the decedent may be necessary to complete disposition, permits, and certificates. I authorize the limited release of the decedent's protected health information to the facility and to the appropriate coroners, medical examiners, funeral providers and governmental authorities for purposes of cremation, issuance of death certificate, and compliance with applicable law.

This authorization expires on:

Fees, Payment and Indemnity

I acknowledge that I am responsible for payment of cremation and related services and that payment is due in accordance with facility policy. I authorize the facility to retain cremated remains, delay final disposition, or assess storage fees until payment in full is received.

Additional Consents and Declarations

Visual Identification: I authorize viewing/identification of the decedent by the Authorizing Agent prior to cremation (subject to facility policies). If not authorized, I understand identification will be by other reasonable means.

Personal Property: I attest that personal property has been removed or that items left with the decedent are authorized for cremation and I release the facility from liability for personal property not removed.

Affirmation

I certify under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief, that I am the person authorized to sign on behalf of the decedent, and that I have read and understood this Authorization and Release.

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