Healthcare Disposition of Remains Form

Healthcare Disposition of Remains Form

Patient Information

Date of Birth:    Gender:

Emergency & Next of Kin

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History (relevant)

Disposition Instructions

Select the disposition method(s) you authorize for your remains (one or more):

Cremation — I direct that my body be cremated. I understand cremation is irreversible and that authorization for cremation includes disposition of cremated remains in accordance with these instructions.

Burial — I direct that my body be interred in a cemetery or burial plot designated below.

Entombment — I authorize placement in a mausoleum or crypt.

Donation to science — I authorize anatomical donation or donation for research/education per applicable law and facility policies.

Disposition at sea — I authorize lawful burial at sea in accordance with applicable regulations.

Other (specify) — please describe below.

Funeral Home / Agent

Organ and Autopsy Instructions

I authorize the donation of organs and/or tissues for transplantation, therapy, research or education as permitted by law.

I authorize an autopsy if required by law or if it is necessary to determine the cause of death. (If denied, check here:)

Removal of Medical Devices

I authorize removal of implanted medical devices (e.g., pacemaker, defibrillator) if required prior to cremation or disposition.

Financial Responsibility

I understand that arrangements for disposition may incur charges. I authorize the funeral home or agent identified above to act on my behalf to the extent necessary to effect my instructions and I accept financial responsibility as indicated below.

Authorization and Certification

By signing below I hereby direct and authorize the disposition of my remains in accordance with the selections and instructions set forth in this document. I authorize my attending physician, medical facility, allied health professionals, and the funeral home to release and disclose medical information, including cause of death where necessary, to effectuate disposition and complete required documentation.

I certify that I am the above-named patient or that I am legally authorized to make disposition decisions on behalf of the patient. If signing as a legal representative, I attest that I have the legal authority to make this directive and will provide documentation of such authority upon request.

I understand that this document may be relied upon by third parties acting in good faith. I release and hold harmless any medical provider, funeral director, cemetery, crematory, and their employees from civil or criminal liability for actions taken in good faith pursuant to this directive, except for actions constituting gross negligence or willful misconduct.

I understand I may revoke or amend this directive at any time by providing a written notice signed and dated by me to the healthcare facility or funeral home. Revocation or amendment will not affect actions already taken in reasonable reliance on this document.

HIPAA / Privacy Acknowledgment

I acknowledge and authorize disclosure of protected health information as necessary to implement these disposition instructions, including disclosure to funeral directors, coroners, transplant organizations, and authorities preparing death certificates.

Guardian / Representative Attestation (if applicable)

If signing as a guardian or legally authorized representative, check the box below and provide supporting information and documentation.

I attest that I am the legal guardian or authorized representative and will provide documentation of authority upon request.

Acknowledgement of Irreversible Actions

I understand that certain actions, including cremation and anatomical removal, are irreversible and that this directive provides authority to perform such actions where selected. I have read and understand these instructions and had the opportunity to ask questions.

Sign Now