Healthcare Life Certificate

HEALTHCARE LIFE CERTIFICATE

This Healthcare Life Certificate is an official attestation prepared for the purpose of verifying that the individual named below is alive on the date of verification. Completion of this certificate requires accurate patient identification, verification details completed by an authorized healthcare facility or representative, and the patient or authorized guardian signature. False statements made herein may subject the signer to civil or criminal penalties.

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information (if applicable)

Policy Number:    Group Number:

Medical Summary

Purpose of Certificate

This certificate is requested for the following purpose(s). Select all that apply:

Pension / Retirement Verification    Insurance Claim    Banking / Financial    Other:

Verification of Life — Healthcare Facility Section

Verification Method (select at least one):   In-person exam   Live video call   Government-issued photo ID reviewed   Other:

Date of Verification:    Time of Verification:

Provider / Verifying Representative Name:    License / ID Number:

Statement of Verification: The healthcare facility representative has performed the verification methods indicated above and confirms that the person identified on this form was alive at the time and date of verification. The facility's representative has completed the facility fields and provided identifying documentation where required.

Authorization and Certification by Patient

I certify under penalty of perjury that the information I have provided on this Healthcare Life Certificate is true and correct to the best of my knowledge. I authorize the release of this certificate and any verification information provided by the healthcare facility to the requesting third party named below for the purpose specified above.

This authorization expires on:

HIPAA Acknowledgment: I acknowledge that I have been informed of my privacy rights and that my health information related to this verification may be disclosed to the requesting third party for the stated purpose.

Release of Liability: I release the healthcare facility and its representatives from liability for disclosures made in good faith pursuant to this certificate. I understand that any intentional falsification of information may subject me to civil or criminal penalties under applicable law.

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