DECEASED PATIENT INFORMATION REQUEST FORM

DECEASED PATIENT INFORMATION REQUEST FORM
*Please attach a copy of the Death Certificate or Obituary
_____________________________________________
______/______/________
________________________
______/______/________
Patient Legal Name
Gender
Date of Birth
Date of Death
_________________________________________________________________________
Last Known Address
_________________________________________________________________________
City
Zip Code
___________________________________________________________
Primary Care Provider Name
___________________________________________
Next of Kin
__________________________________________
POA (Power of Attorney) Name / Representative of the Estate
(_____) _______-____________
Next of Kin Phone Number
(_____) _______-____________
Phone Number POA / Representative of the Estate
__________________________________________________________________________
POA Name (Power of Attorney) / Representative of the Estate Address:
__________________________________________________________________________
City
Zip Code
_____________________________________________
Print Name of person completing this form:
(_____) _______-____________
FOR OFFICE USE ONLY
HIM Process Verified/Completed by: _____________________________
 Copy of Obituary or Death Certificate
 Care Guidelines
 Appointments Canceled
 Patient Portal Un-enrollment
PFS Process Verified/Completed by: ______________________________
Date: _____/______/______
 Reminders
 Future Orders
 Recalls
 NextGen Share
Date: _____/______/______
Send Completed form to Fax number 360-428-6408 or email Address to: [email protected]
Or 1400 E Kincaid St. Mount Vernon, WA 98274