Healthcare Obituary Layout

Healthcare Obituary Layout

Patient Information

Patient Name:

Contact and Representative

Biographical Narrative and Funeral Details

Medical and Publication Permissions

Include cause of death in obituary:    If yes, specify cause to be published:

Photographs and image release for publication:    I authorize the facility to publish photographs provided with this obituary.

Permission to include limited medical information beyond cause of death (e.g., significant illnesses, hospice care):    I authorize limited medical details as provided in this form.

Newspaper    Hospital/Facility Bulletin    Community Newsletter    Print Memorial Program

Legal Authorization and Release

By signing below, I, the Authorized Representative named above, certify that I am legally authorized to request the preparation and publication of the obituary for the deceased patient identified in this form. I authorize the release and disclosure of the limited protected health information necessary to prepare and publish the obituary as described herein. The disclosure is limited to the biographical, service, and medical details expressly indicated on this form.

I acknowledge that I may revoke this authorization at any time by delivering written notice to the facility; however, such revocation will not affect any action taken in reliance on this authorization prior to receipt of the revocation. This release does not authorize the release of the decedent's full medical record or unrelated medical details beyond those specified.

I agree to indemnify and hold harmless the facility and its employees from any claim, liability, or expense arising from publication of the obituary information as provided herein, including claims based on accuracy of information furnished by me or limitations on the scope of authorized disclosures.

HIPAA Acknowledgment: I acknowledge that I have read and received the facility's privacy practices summary concerning use and disclosure of protected health information for obituary publication purposes, and I consent to the limited disclosure described in this form.

Acknowledgment of Accuracy: I certify under penalty of perjury that the information I have provided on this form is true and correct to the best of my knowledge and that I have the authority to act on behalf of the decedent regarding publication and disposition of obituary information.

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