Healthcare Disposition Form

HEALTHCARE DISPOSITION FORM

This Healthcare Disposition Form documents the patient's instructions and authorization regarding the disposition of bodily remains, implantable medical devices, retained medical specimens, and protected health information following death or when no longer required by the treating facility. Completion of this form constitutes a voluntary, written directive intended to guide the health care provider and authorized agents in carrying out the patient's disposition preferences and authorizes release of protected health information as necessary to effectuate those preferences.

Patient Information

Patient Name:

Medical Record No.: Date of Birth: Gender:

Disposition of Remains

Select one or more preferred disposition options. If multiple options are selected, the health care provider and authorized agent will follow the order of priority below in good faith to effect the patient's intent.

Burial (Interment)

Cremation

Donation of body for anatomical or medical education/research

Release to family or designated agent for private disposition

Disposition of Medical Records & Specimens

The undersigned authorizes the health care provider to take the following actions with respect to medical records, residual tissue, diagnostic specimens, and biologic materials:

Release medical records and/or specimens to:

Transfer records to an archival repository or authorized custodian named below:

Permit use of de-identified specimens for research

Destroy records and specimens after

Implantable Devices & Prosthetics

For implanted devices, prosthetic materials, and external medical equipment, select disposition preference:

Return to family or designated agent

Dispose as regulated medical waste

Donate for educational or demonstration purposes where lawful

Organ and Tissue Donation

Indicate organ and tissue donation preferences:

Yes — donate organs and tissues for transplantation where eligible

Yes — allow tissues or organs for research or education

No — do not authorize organ or tissue donation

Legal Acknowledgments and Authorization

By signing below, I certify that I have the legal capacity to make these disposition instructions. If signed by a legally authorized representative, I certify that I am authorized under applicable law to execute this form on the patient's behalf and will provide documentation of such authority upon request.

I hereby authorize the release of protected health information (PHI) to the person(s) and organizations identified in this form as reasonably necessary to effectuate the disposition instructions. I understand that PHI disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law to the extent allowed by law. I further acknowledge that I may revoke this authorization at any time by submitting a written revocation to the health care provider, except to the extent that the provider or its agents have acted in reliance on this authorization.

This authorization shall remain in effect until: unless earlier revoked in writing. If no date is entered, this authorization will remain effective until superseded or revoked as permitted by law.

I release the health care provider, its employees and agents from civil or criminal liability for compliance with these instructions provided they act in good faith and in accordance with applicable law. I understand that reasonable efforts will be made to follow my instructions, but that compliance may be limited by legal, medical, or logistical constraints.

Authority and Representative Information (if applicable)

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