Attachment_III_-_Indigent_Burial_Services_Form.docx

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MORTUARY SERVICES FOR CLINICAL CENTER PATIENTS AND FAMILIES
Solicitation number
16-014330
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SWD INDIGENT BURIAL SERVICES FORM

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SWD Indigent Burial Services Form This form is only to be used for indigent patients who expire at the NIH Clinical Center.

SWD Indigent Burial Services Form – FAQ’s & GUIDELINES Arrangement Survey Form VITAL STATISTICS Pope Funeral Home Complete if patient expires at the NIH Clinical Center Contractor – [INSERT CONTRACT VENDOR CONTACT INFORMATION]ATTN FUNERAL HOME: Please send bill to NIH/CC Social Work Department 10 Center Drive, Bldg 10CRC Rm 2-3581, Bethesda, MD 20892-5471

Patient Name:
Patient Age:
Patient Care Unit:
Patient MRN:
Next of Kin & Relationship:
Protocol Number:

Next of Kin Address:

Institute/Branch:

Communicable Disease: ☐No ☐Yes ________________________

Next of Kin Phone Number:

CREMATION

Or

BODY PREPARATION

☐ Cremation ☐ Urn and engraving Name of Person Identifying Remains: __________________________ Relationship: ___________________ Phone #: ___________________

☐ Embalming ☐ Provide Casket

VIEWING

And/or

FUNERAL SERVICE

☐ Viewing ☐ Funeral Service

Services selected above to be held at:

☐ Contract Funeral Home ☐ Local MD/DC/VA Church/Community Center (name & address, if available): _______________________________________________

DISPOSITION OF REMAINS
☐ Local Burial

☐ Domestic Shipment* ☐ International Shipment*(applicable to patients whose address of record is outside the US)

* For CREMAINS provide address, if available: __________________

* For Bodily Remains provide City/State/Country to identify Closest Major Airport, per contract: _________________________________

Justification of Patient/Family’s Indigent Status:

Religious Considerations/Other Instructions:

Arrangements Have Been Discussed with Family:
☐ Yes
☐ No
Social Worker Name/Signature:
Date:
Kathleen Baxley, Chief, SWD/Signature:
Date:

Admissions Staff who faxed form to [VENDOR]:

Date:

Time:

REV 03/2016

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