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

NIH CLINICAL CENTER

FUNERAL HOME SERVICES REQUEST FORM (Non-Indigent)

INSTRUCTIONS: Please complete this form to request transportation of bodies for autopsy and/or other funeral services that are not covered under services for indigent patients. Services are paid for by the Institute/Center and an Outside Medical Services Form (2541) approving amount of funding must accompany this form.

FUNERAL HOME PLEASE SEND INVOICE TO:

PATIENT DEMOGRAPHICS

Patient Name: Address:

Date of Birth/Age: MRN: Communicable Disease: Outside Expiration: Embalmed:

Institute/Branch: Protocol Number: Religious Considerations/Other Instructions:

Next of Kin Name: Address: Phone:

Email:

DATE OF DEATH

Outside Expiration: Inside (CC) Expiration:

FUNERAL HOME PROVIDING SERVICES

Name: Point of Contact:

Address: Phone:

Fax:

SERVICES AUTHORIZED BY IC (Check all that are authorized)

Transportation:

One way transport from Clinical Center:

To:

Multi-stop transport:

Removal location:

Final Destination:

Transportation services cross state lines

Air Transport

FAX#: 301-594-5282

PHONE#: 301-496-2341

NIH CLINICAL CENTER

PATIENT SUPPORT SERVICES DEPARTMENT

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

YES or NOYES or NO

Body Preparation Crate/Uncrate remains shipped by air before arrival to Clinical Center Ice or frozen gel packets for transport to Clinical Center Embalming post autopsy Provide Casket

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

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

Cremation

Yes

No

Urn type:

Engraving:

Name of Person Identifying Remains:

Relationship: Phone:

Mailing of cremains:

Disposition of Remains

Domestic Shipment (address of family’s funeral home of choice):

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

Death Certificates per contract

IC Point of Contact Name: Phone:

Date of Request:

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

Notes:

FUNERAL HOME PLEASE SEND INVOICE TO: