Healthcare Release of Decedent

HEALTHCARE RELEASE OF DECEDENT

Facility Name:   Facility Location/Unit:

DECEDENT INFORMATION

Date of Birth:   Date of Death:   Medical Record / ID #:

REQUESTOR / AUTHORIZED REPRESENTATIVE

Phone:   Email:

LEGAL AUTHORITY

By checking the applicable box below, requester asserts legal authority to direct disposition and obtain records and/or possession of remains. Facility may require presentation of documentation supporting authority.

Select authority (check all that apply) Next of kin Executor or Personal Representative (attach Letters Testamentary or Court Order) Agent under Durable Power of Attorney for Health Care / Advance Directive Funeral director or authorized funeral home representative Other (describe below)

SCOPE OF AUTHORIZATION

I authorize the facility to release the following items as indicated below:

Release decedent's remains to:

Release medical records, lab results, and other protected health information to requested recipient If checked, release to:

Release personal property and effects to requester List of personal property to be released:

Release tissue, specimens, or biological materials (if retained) for transfer to authorized recipient Description / recipient:

ORGAN / TISSUE DONATION & SPECIAL CONDITIONS

To my knowledge, the decedent had indicated the following regarding organ or tissue donation:

Donor designation exists — proceed in accordance with donor documentation and applicable law. No donor designation known to requester. Unknown

AUTHORIZATION, REPRESENTATIONS, AND INDEMNIFICATION

I hereby authorize the facility to release possession of the decedent's remains, personal property, and/or protected health information as indicated above. I represent and certify under penalty of perjury that I am authorized under applicable law to make this request and direct disposition of the decedent's remains or to obtain the decedent's medical information. I agree to provide satisfactory proof of authority upon request.

I agree to hold harmless and indemnify the facility, its officers, employees and agents from any claims, liabilities, costs or expenses (including reasonable attorneys' fees) arising from the release and transfer of remains, records, specimens or property pursuant to this authorization, except to the extent resulting from the facility's gross negligence or willful misconduct.

I acknowledge that the facility may require completion of additional documentation, verification of identity, or official court orders prior to release. I understand that providing false or misleading information may subject me to civil or criminal penalties under applicable law.

HIPAA AUTHORIZATION / MEDICAL INFORMATION RELEASE

I authorize the disclosure of the decedent's protected health information as necessary to fulfill this release and to facilitate transfer of remains, funeral arrangements, and processing of death-related documentation. This authorization includes, where applicable, the release of diagnoses, treatment records, laboratory results, radiology reports, and other information reasonably necessary to accomplish the purposes set forth in this form.

Expiration of Authorization: This authorization expires on or upon completion of the actions reasonably necessary to carry out this release, whichever occurs first.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. Revocation should be submitted to the facility's records department in writing.

INFECTIOUS DISEASE / SPECIAL HANDLING

To the extent known, the facility will disclose significant infectious disease concerns that affect safe handling and transport of remains. The requester accepts responsibility to ensure that any receiving party is informed of such conditions and will follow applicable public health and safety requirements.

ATTACHMENTS / DOCUMENTS PROVIDED

Documents accompanying this request (check and list as provided):

CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the applicable jurisdiction that the information provided in this form is true and correct to the best of my knowledge, that I have the authority to act as indicated, and that I authorize the facility to release the decedent's remains, property, and/or protected health information as specified. I acknowledge receipt of a copy of this authorization upon request.

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