Healthcare Memorial Document

HEALTHCARE MEMORIAL DOCUMENT

This Healthcare Memorial Document is a legally binding expression of my wishes regarding post-mortem medical information, disposition of my remains, organ and tissue donation, and the release of protected health information (PHI) for the purposes of memorial planning, estate administration, and other necessary actions following my death. I direct healthcare providers, custodians of my medical records, and related institutions to follow the provisions set forth below to the extent permitted by law.

1. PATIENT INFORMATION

Patient Name:

Date of Birth:    Gender: Male Female Other

2. EMERGENCY & NEXT OF KIN

3. INSURANCE & PROVIDER

4. MEDICAL HISTORY (SUMMARY)

5. MEMORIAL, DISPOSITION & DONATION INSTRUCTIONS

Organ and Tissue Donation: I consent to anatomical gift (organ and/or tissue donation) as permitted by law. I do not consent to organ or tissue donation.

Autopsy: Allow autopsy if required for cause of death or identification. Prohibit autopsy except as required by law.

Disposition Preference: Cremation Burial Other:

6. AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AFTER DEATH

I authorize any healthcare provider, health plan, medical examiner, hospital, clinic, or other custodian of my medical records to disclose and release my protected health information (PHI) after my death as necessary to carry out the directions in this document, to individuals named below, and to representatives, agents, or institutions acting on their behalf.

Scope of Records to be Released (check all that apply):
Medical records, history and progress notes Mental health records HIV-related records Substance abuse treatment records Genetic test results

Purpose of Disclosure:

This authorization permits disclosure of sensitive categories of information where permitted by law. I understand that some categories of information may require additional consent under applicable law and that the custodian of records may require confirmation of identity or a certified copy of this document prior to disclosure.

7. HIPAA PRIVACY ACKNOWLEDGMENT

I acknowledge that I have read and understand that this document authorizes the release of my protected health information after my death. I understand my rights under applicable privacy laws, including the right to revoke this authorization prior to my death by providing written notice to the custodian of records, except to the extent that action has already been taken in reliance on this authorization.

Authorization Effective Date:    Authorization Expiration Date (if any):

8. ATTORNEY-IN-FACT OR GUARDIAN

If this document is executed by an attorney-in-fact under a durable power of attorney, or by a legally appointed guardian on my behalf, check the appropriate box and provide the name and authority.

Signed by Attorney-in-Fact / Agent under Durable Power of Attorney Signed by Court-Appointed Guardian

9. REVOCATION, LIMITATIONS & LEGAL NOTICE

Revocation: I may revoke this authorization at any time by providing a written revocation to the custodian(s) of my records. Revocation will not affect disclosures made in good faith prior to receipt of revocation. If no expiration date is provided, this authorization remains in effect until revoked in writing.

Limitation of Liability: Custodians of records and other entities acting in good faith and in compliance with this document and applicable law are released from liability for good faith disclosures made pursuant to this authorization. This document does not obligate any provider to act contrary to law, to violate ethical or contractual obligations, or to incur expenses inconsistent with their policies.

Governing Law: This document shall be governed by the laws of the state in which the custodian of records is located, to the extent such laws apply to the release of PHI and disposition of remains.

10. CERTIFICATION

I certify under penalty of perjury that I am of legal age and mentally competent to execute this document, that I have read and understand its contents, that the instructions herein reflect my directions concerning post-mortem handling of my medical information and disposition preferences, and that I sign this document voluntarily.

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