Healthcare Cremation Services Itemization

Healthcare Cremation Services Itemization

Provider / Facility Information

Facility Name:

Decedent / Patient Information

Date of Birth:    Date of Death:

Authorizing Agent / Billing Contact

Phone:    Email:

Itemized Services and Fees

Provide an itemized description of services, supplies, and fees. Enter amounts in U.S. dollars.

Summary of Charges

Subtotal:    Sales Tax / Fees:    Total:

Optional Services / Selections

Witnessed cremation requested

Refrigeration prior to cremation

Transportation from facility to crematory

Private identification viewing before cremation

Authorization, Certifications, and Acknowledgments

By signing below, I certify under penalty of perjury that I am the person authorized to direct the disposition of the decedent named above or am legally authorized to act on behalf of that person. I authorize the Facility and its agents to perform the cremation, handling, and disposition described in this itemization and any accompanying paperwork. I acknowledge that cremation is an irreversible process and that the Facility has provided a description of the procedures that will be performed.

I acknowledge and agree that the Facility may remove medical devices, prosthetics, and other items that could create a hazard prior to cremation. I understand that the Facility will make reasonable efforts to remove and dispose of such items and that some devices may be retained for regulatory or safety reasons.

I understand that the Facility cannot guarantee the recovery of all cremated remains and that the size, appearance, and quantity of cremated remains may vary. I release and discharge the Facility and its employees, agents, and assigns from any liability or claim arising from ordinary handling, cremation, and final disposition, except for gross negligence or willful misconduct.

I further agree to indemnify, defend, and hold harmless the Facility from any third-party claims arising out of my representations concerning authority to direct disposition or any incorrect information provided in this form.

Authorization to withdraw: This authorization may be revoked in writing prior to commencement of cremation. Once cremation has begun, this authorization and consent cannot be revoked.

Fees and payment: I agree to pay the amounts itemized above in accordance with the payment terms set by the Facility. Outstanding balances may be subject to collection and the Facility may retain possession of cremated remains until balances are paid in full.

Unclaimed remains: If cremated remains are not claimed or directed for disposition within a reasonable period after notification, the Facility may arrange for disposition in accordance with its policies.

I acknowledge and consent to the statements above regarding authorization, removal of devices, release and indemnification.

I acknowledge responsibility for payment of the itemized charges and understand the Facility's payment and retention policies.

I understand my right to withdraw this authorization prior to commencement of cremation by written notice to the Facility.

Privacy / HIPAA Acknowledgment

I consent to the release of the decedent's relevant medical and identifying information to the Facility, crematory, or their agents to effectuate the services described herein. I acknowledge receipt of the Facility's privacy practices and authorize the use and disclosure of protected health information as necessary to perform cremation and related services.

I acknowledge the privacy statement and authorize required disclosures for the purpose of disposition and billing.

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