Healthcare Embalm Form

HEALTHCARE EMBALM AUTHORIZATION

Decedent / Patient Information

Date of birth:    Gender:    Medical record or hospital ID:

Phone:    Social Security/ID last four digits:

Authorizing Representative

Address:    Phone:

Authorization for Embalming and Related Procedures

I, the undersigned authorizing representative, hereby grant permission to the healthcare facility and the contracted embalming provider to perform embalming, restorative treatment, and other preparatory procedures reasonably necessary to preserve and present the decedent for transportation, viewing, and funeral services. This authorization includes the use of standard embalming chemicals, arterial and cavity treatment, topical disinfectants, and restorative cosmetics as appropriate.

Full arterial and cavity embalming    Temporary (short-term) embalming    Restorative/reconstructive cosmetic procedures    Preparation following autopsy or surgical procedures

Medical, Device, and Safety Information

Does the decedent have any infectious or communicable disease known to you? If yes, specify:

Presence of implanted devices or hazardous materials (check all that apply):

Pacemaker or implantable defibrillator    Prosthetic devices (e.g., joint replacements)    Other medical implants    If other, describe:

I authorize the removal of a pacemaker, defibrillator, or other implant for safety during embalming and transportation: Yes    No

Personal Effects and Property

The facility and embalming provider may remove, inventory, and retain personal effects as necessary to perform embalming and safe transport. Items that may be removed include jewelry, clothing, prosthetics, and medical devices. If property is removed it will be documented and retained in accordance with facility policy until claimed by the authorized representative.

Authorizations, Warranties, and Release

By signing below, I represent that I am the legal next of kin or authorized representative empowered to grant permission for embalming and related procedures. I warrant that the information provided on this form is true and complete to the best of my knowledge. I consent to disclosure of medical and identifying information to personnel performing embalming as necessary to complete the procedures.

I hereby release, hold harmless, and indemnify the healthcare facility, its employees, agents, and the embalming provider from any liability, claims, or losses arising out of the embalming procedures authorized herein, except where caused by willful misconduct or gross negligence. I understand embalming alters the natural state of the body and that certain conditions may render the decedent unfit for viewing or further cosmetic restoration.

Organ/Tissue Donation and Autopsy

To the best of my knowledge, organ and tissue donation and prior consent or refusal has been handled as follows:

If an autopsy is required or has been performed, embalming procedures may be modified. I understand that embalming may be delayed until necessary medicolegal requirements are satisfied.

Acknowledgment of Rights and Revocation

I understand that I may revoke this authorization prior to commencement of embalming by providing written notice to the facility. Once embalming has begun or the body has been altered in accordance with this authorization, revocation will not restore the decedent to the original condition nor will it relieve me of any liability for services already rendered.

This authorization expires on the date indicated below or upon completion of the services described, whichever occurs first.

HIPAA / Privacy Release

I authorize the release of medical information and records necessary for the identification, preparation, and embalming of the decedent to facility staff, the embalming provider, and funeral service personnel. I understand that this authorization permits disclosure of protected health information for the limited and specific purposes described above.

I acknowledge that I have read and understand this authorization and that questions regarding the nature and effect of this authorization have been answered to my satisfaction.

Fees and Transportation

I understand that embalming and related services are subject to fees charged by the embalming provider or facility and that additional charges may apply for special restorative work, removal of implants, extended refrigeration, or transportation. I accept responsibility for payment of all charges as arranged with the facility or funeral home.

Additional Instructions

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