Healthcare Funeral Checklist

HEALTHCARE FUNERAL CHECKLIST

Purpose: This form documents the patient's preferences for disposition and related arrangements and provides the healthcare facility with written authorization to follow those preferences after pronouncement of death. Completion of this form creates legally relevant instructions for clinical and administrative staff and may be relied upon in lieu of later oral directions when applicable.

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance & Responsible Party

Medical History (Relevant to Disposition)

Disposition & Funeral Preferences

Preferred disposition (check all that apply): Burial Cremation Anatomical donation for transplant/research Coroner/Medical Examiner determination required

Permit funeral home to take custody of the decedent upon release: Yes No

Legal & Administrative Directives

Organ donation: I consent to organ/tissue donation I do not consent Registry/Authorization number:

Autopsy consent: Consent to autopsy if medically indicated Refuse autopsy Limited to clarification of cause of death

Medical devices / implants: staff may remove implantable devices (e.g., pacemaker) prior to cremation or donation if required: Permit removal Deny removal

Notifications & Documentation

Death certificate to list: Legal name as above; Informant for death certificate:

Required notifications by facility (check to authorize facility to notify): Social Security Insurance Carrier(s) Veterans Affairs / Military Records Employer

Post-Death Facility Checklist (For Staff)

Actions to be completed at time of death (staff to initial and date):

HIPAA / Privacy Acknowledgment

I acknowledge that the facility will use and disclose protected health information as necessary to carry out the disposition and notification duties set forth in this form, consistent with applicable privacy law. I understand that I may be contacted for additional information to complete official documentation.

Acknowledgment: I acknowledge and consent to the privacy and disclosure provisions above.

Authorization Duration & Certification

This authorization is effective immediately upon signature below and remains in effect until unless revoked in writing. The signer certifies that the information and instructions provided are accurate and that the signer is legally authorized to provide these instructions.

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