13. NIH Clinical Center Funeral Home Services Request Form - Indigent.pdf

NIH CLINICAL CENTER

INDIGENT FUNERAL HOME SERVICES REQUEST FORM

FUNERAL HOME PLEASE SEND INVOICE TO:

PATIENT DEMOGRAPHICS

Patient Name: Address:

Date of Birth/Age: MRN: Communicable Disease:

Institute/Branch: Protocol Number:

Next of Kin Name: Address: Phone:

Email:

DATE OF DEATH:

SERVICES AUTHORIZED BY CC (Check all that are authorized)

FAX#: 301-594-5282

PHONE#: 301-496-2341

NIH CLINICAL CENTER

PATIENT SUPPORT SERVICES DEPARTMENT

10 CENTER DRIVE, 1-5649, BETHESDA, MD 20892

NO or YES

Body

Preparation

Embalming Provide Casket (specify type):

Cremation

Yes

No

Urn type:

Engraving:

Name of Person Identifying Remains:

Relationship: Phone:

Mailing of cremains to (Name and Address):

OR No Embalming

OR

Local Burial in Contract Cemetery Domestic Shipment to closest major airport city/state address of record International Shipment to closest major airport to address of record outside US (Specify Below)

Specify disease:

Viewing only (specify name and address of contract funeral home)

Yes No

Funeral Services (Local Only)

Viewing and Funeral Service (specify name and address of contract funeral home)

Funeral Home POC Name: Phone: Fax:

Mail Copies* of Death Certificates to (Name & Address):

*Per Contract, three copies will be mailed to one address.

REV AUG 2019

Disposition of Remains

Domestic Shipment - Name & Address of family’s funeral home of choice:

International Shipment** (applicable to patients whose address of record is outside of US):

Social Worker Name: Supervisor Signature:

Date of Request:

Name of Admissions Assistant who faxed form: Date & Time of Fax:

CC Admissions Notes:

** Remains shipped to the nearest airport; international ground transportation not provided.

JUSTIFICATION OF PATIENT/NEXT OF KIN'S INDIGENT STATUS:

RELIGIOUS CONSIDERATIONS/OTHER INSTRUCTIONS

ARRANGEMENTS HAVE BEEN DISCUSSED WITH NEXT OF KIN: YES NO

INDIGENT FUNERAL HOME SERVICES REQUEST FORM PAGE 2

PATIENT NAME: MRN:

Phone: Fax: Funeral Home POC Name:

SWD Supervisory Approval:

Name of Next of Kin discussed with (Print): Date

REV AUG 2019

FUNERAL HOME PLEASE SEND INVOICE TO: