Healthcare Cremation Services Consent

HEALTHCARE CREMATION SERVICES CONSENT

Patient Name:

Date of Birth:    Medical Record Number:

Facility and Contact Information

Type of Consent

 Pre-need consent by patient (consent executed prior to death)

 At-time consent by legal representative or next-of-kin (consent executed following death)

Authorization and Scope of Consent

I hereby authorize the Facility and any licensed crematory, funeral establishment, or agent acting on their behalf to cremate the remains of the above-named patient upon death, and to perform all acts reasonably necessary to effect cremation, including but not limited to identification verification, transportation, preparation, removal of medical devices and prosthetic implants when required for safe cremation, and processing of cremated remains.

I acknowledge that certain medical devices (for example, pacemakers, defibrillators) must be removed prior to cremation and that such removal may be performed by Facility staff, a licensed embalmer, or crematory personnel at the discretion of the Facility. I further authorize such removal as necessary for safe cremation and accept that additional fees may apply.

Disposition of Cremated Remains

I direct that the cremated remains be handled as follows (select one or provide instructions):

 Return to designated recipient:

 Transfer to licensed funeral service or cemetery for interment or other disposition. Name of service:

 Scattering as directed below:

If no disposition instructions are provided or if the designated recipient is unable to receive the remains, I authorize the Facility to deliver the cremated remains to a licensed crematory or funeral service for disposition in accordance with applicable law.

Personal Effects and Hazardous Materials

Personal property found with the decedent will be handled as follows. I direct that the following items be returned with the remains (if feasible) or retained by the Facility (list items and instructions):

I understand that hazardous materials (including certain prosthetics, implanted devices containing lithium or other batteries, or infectious waste) may be removed and disposed of in accordance with law and accepted practice. I release the Facility and crematory from liability for the lawful destruction or disposal of such items.

Medical Examiner, Autopsy, and Organ Donation

I understand that if the death is subject to investigation by a medical examiner or coroner, or if an autopsy is required, cremation may be delayed until release by the appropriate authority. I acknowledge that organ or tissue donation arrangements may affect timing and disposition and that such procedures are separate from this authorization.

Fees, Liability, and Indemnification

I acknowledge that cremation, transportation, removal of medical devices, and other services may incur fees. I agree to be responsible for charges incurred by the Facility or its agents to the extent permitted by law. To the fullest extent permitted by law, I hereby release and hold harmless the Facility, its officers, employees, agents, and the crematory from any liability for claims arising from cremation and disposition conducted in accordance with this consent and applicable law, except for acts of gross negligence or willful misconduct.

HIPAA / Privacy Authorization

I authorize the release of any medical or identifying information about the patient that is necessary to carry out the disposition and cremation, including communication with funeral services, crematory personnel, and governmental authorities. I understand that records disclosed under this authorization may include protected health information and that this authorization permits such disclosure for the purposes described herein.

Authority to Sign and Certification

By signing below I certify under penalty of perjury that I am authorized to direct disposition and to execute this consent for the decedent named above. I further certify that the statements made herein are true and accurate to the best of my knowledge.

I attest that my authority is (check applicable box and provide documentation if required):

 Patient (self-consent)

 Legal guardian or conservator

 Designated agent under durable power of attorney for health care

 Next-of-kin / closest living relative

Acknowledgment of Rights and Revocation

I understand that this consent may be revoked by me in writing at any time prior to death if I am the patient, or by the person or authority who executed this consent in accordance with applicable law if executed after death. Revocation will not affect actions taken in reliance on this consent prior to receipt of the revocation.

Medical and Emergency Contact Information

Additional Instructions / Notes

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