Healthcare Funeral Service Contract

HEALTHCARE FUNERAL SERVICE CONTRACT

This Funeral Service Contract (Contract) is entered into between the undersigned Authorized Representative and the Funeral Service Provider identified below. The Authorized Representative affirms authority to arrange disposition of the decedent named in this Contract. The Funeral Service Provider will provide the services and merchandise described in this Contract in accordance with the terms, acknowledgments, consents, and disclosures set forth herein.

PARTIES & IDENTIFICATION

DECEDENT / PATIENT INFORMATION

Decedent Name:

Date of Birth:    Date of Death:

PATIENT / MEDICAL HISTORY

EMERGENCY / CONTACT INFORMATION

INSURANCE & PAYMENT

Payment Responsibility: The Authorized Representative certifies financial responsibility for charges not paid by insurance or other third-party payors.

SELECTED SERVICES & MERCHANDISE

Basic Services Fee: $ (includes administrative, arrangement, coordination and standard staff)

Embalming:   Fee: $ Embalming is a chemical process and is not required by law except in certain cases. The Authorized Representative consents to embalming if selected.

Cremation:   Fee: $

Casket / Urn Merchandise:   Estimated Cost: $

Transportation / Transfer from Healthcare Facility: $

Refrigeration / Care of Remains: $

Death Certificate Copies (per copy): $

Applicable taxes, third-party fees, cemetery or crematory fees and additional services requested will be added to the total invoice. The Funeral Service Provider will provide a written final invoice prior to final disposition when practicable.

DISPOSITION METHOD & AUTHORIZATIONS

Disposition selected: Burial    Cremation    Entombment    Anatomical Donation

Cremation Consent Acknowledgment: If cremation is selected, the Authorized Representative acknowledges that cremation is an irreversible process. The Funeral Service Provider shall complete cremation only after obtaining all required legal permits and authorizations.

Authorization to Embalm and Prepare Remains: The Authorized Representative authorizes the Funeral Service Provider and its agents to embalm, refrigerate, sanitize, dress, cosmetize, and otherwise prepare the remains in a commercially reasonable manner when requested or required. The Funeral Service Provider will employ reasonable care but is not liable for deterioration of remains or for conditions unknown at time of transfer.

RELEASES, CONSENTS & HIPAA AUTHORIZATION

Authorization to Release Records: The Authorized Representative authorizes the release of medical and facility records necessary to complete the death certificate and other legal filings. This authorization includes limited disclosure of protected health information to the Funeral Service Provider, crematory, cemetery, coroner, and governmental agencies for the purpose of disposition and certification. This authorization expires on:

Privacy Notice Acknowledgment: I acknowledge receipt of the Funeral Service Provider's privacy practices and authorize release of information as specified above.

TERMS, PAYMENT & LIMITATION OF LIABILITY

Payment Terms: The Authorized Representative agrees to pay all charges due upon presentation of invoice unless other arrangements are documented and signed by the Funeral Service Provider. Where insurance benefits apply, the Authorized Representative remains ultimately responsible for unpaid balances.

Cancellation: If arrangements are canceled by the Authorized Representative after services are performed or merchandise ordered, the Authorized Representative will be responsible for all costs incurred and for reasonable cancellation charges as determined by the Funeral Service Provider.

Indemnification and Release: To the fullest extent permitted by law, the Authorized Representative releases, indemnifies and holds harmless the Funeral Service Provider, its employees and agents from any and all claims, liabilities, damages, costs and expenses arising from the performance of services under this Contract, except for gross negligence or willful misconduct.

Limitation of Liability: The Funeral Service Provider's liability for any claim arising out of services provided under this Contract shall not exceed the total amount actually paid under this Contract. In no event shall the Funeral Service Provider be liable for consequential or punitive damages.

LEGAL ACKNOWLEDGMENTS

Authority to Direct Disposition: The Authorized Representative affirms under penalty of perjury that they are legally authorized to direct the disposition of the decedent's remains, that the information supplied in this Contract is true and correct, and that they will provide documentation establishing authority if requested by the Funeral Service Provider or governmental authorities.

Compliance with Law: All services provided pursuant to this Contract shall comply with applicable federal, state and local law, including public health and transportation regulations. Where legal restrictions conflict with requested services, the Funeral Service Provider shall comply with law and notify the Authorized Representative of alternatives.

ACKNOWLEDGMENT & CERTIFICATION

By signing below, the Authorized Representative certifies they have read and understand this Contract, consent to the services and authorizations herein, and agree to be bound by the terms, charges, and acknowledgments contained in this Contract.

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