Authorization For Autopsy - Parkland Health & Hospital System printable pdf download

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PARKLAND HEALTH & HOSPITAL SYSTEM

Dallas, Texas

AUTHORIZATION FOR AUTOPSY

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CON130

Patient Information:

Date of Death: ___ /___ /___

Time of Death: ___:___ Military Time

Service/Location:

For all Infant Deaths: Weight ______________________ Grams

Still Birth

Live Birth

Time of Birth: ___:___ Military Time

Attending Physician: (printed name) ________________________________________

Attending Physician ID No.:

Persons Authorized to Consent to Postmortem Examination or Autopsy:

Consent for a postmortem examination or autopsy may be given by any following persons, who are reasonably available, in the order of priority listed:

• the spouse of the decedent;

• the person acting as guardian of the person of the decedent at the time of death or the executor or administrator of the decedent’s estate;

• the adult children of the decedent;

Legally appointed guardian

• the parents of the decedent; and

• the adult siblings of the decedent.

If there is more than one person of the same relation entitled to give consent to a postmortem examination or autopsy, consent may be given by a member

of the same relationship unless another person of the same relationship ﬁ les an objection with the physician, medical examiner, justice of the peace, or

county judge. If an objection is ﬁ led, the consent may be given only by a majority of the persons of the same relationship of the class who are reasonably

available. An example of this would be multiple surviving adult children.

A person may not give consent if, at the time of the decedent’s death, a person granted higher priority as listed above is reasonably available to give

consent or to ﬁ le an objection to a postmortem examination or autopsy.

Medical power of attorney void at time of death

Authorized Consent for Autopsy:

I, (printed name) ________________________________________________________________, being the individual authorized to consent to an

autopsy, hereby consent the Department of Pathology to perform an autopsy on the body of the patient named above, to determine the cause of death, to

document existing medical conditions, and to provide information to physicians that may contribute to the care and treatment of living patients. I authorize

the removal, examination, preservation, study, and retention of organs, tissues, prosthetic/ implantable devices, and ﬂ uids as the Pathologist deems proper

for diagnostic, education, quality improvement, and research purposes. I understand that organs and tissues not needed for diagnostic, education, quality

improvement, or research purposes will be disposed of as deemed appropriate by the Department of Pathology or as otherwise required by law. This

authority shall be limited only by the conditions expressly stated here:

Restrictions or special limitations: (please check one)

None. Permission is granted for a complete autopsy, with removal, examination, and retention of materials as the pathologists deem proper for the

purposes set forth above and for the disposition of such material as the pathologists or hospital determines.

Permission is granted for an autopsy with restrictions or special limitations as speciﬁ ed on the Texas Department of State Health Services Form

VS-200.

You must inform the family that they can request a

Acknowledgements: (please conﬁ rm by checking each statement)

nonaffilated hospital to perform the autopsy

I have been given the opportunity to ask any questions that I may have regarding the scope or purpose of the autopsy.

I have been informed that a) I may request that a non-afﬁ liated physician at a non-afﬁ liated hospital/institution perform the postmortem examination

or autopsy; b) I may request that a non-afﬁ liated physician at a non-afﬁ liated hospital/institution review the postmortem examination or autopsy

conducted by Parkland Hospital; c) I will be responsible for any additional costs incurred as a result of these request(s).

I authorize the release of all medical information (including medical records, glass slides, and parafﬁ n blocks) which may be needed to complete the

autopsy on the above patient to the Department of Pathology

__________________________________________________

________________________________________________ ______________

_______________

Authorizing Person’s Signature

Relationship to Deceased

Phone Number

Date

Time