Form Didd 0599 – Fill Out and Use This PDF

STATE OF TENNESSEE

DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (DIDD)

DIDD AUTOPSY PERMIT FORM

Center/Regional Office/Provider Agency:
Address:			Telephone #:			Fax #:
			E-mail Address:

Part 1.

Deceased Information:

Name:

Date of Birth:

Age:

SS #:

Sex:

Race:

Part 2.

Next of Kin Information:

Name:

Relationship:

Address:

Telephone #:

Fax #:

E-mail Address:

Part 3. Custody of Body:

Explanation: Only the next of kin who assumes custody of the body for the purpose of burial may authorize the performance of an autopsy.

Statement: I affirm that I am the next of kin who assumes custody of the body for the purpose of burial.

Part 4.

Request:

Explanation: As the next of kin of the deceased person, you may request that an autopsy be performed.

Statement: I request a Forensic Medical pathologist to perform an autopsy on the decedent’s body.

DIDD-0599 (Rev. 9/11)

DIDD AUTOPSY PERMIT FORM

Part 5. Completeness of Autopsy:

Explanation: You or the pathologist may agree to limit the scope of the autopsy to answer specific questions of interest. You may limit the autopsy. That is, you may have the pathologist perform only part of a standard or complete autopsy.

Authorization: I authorize the autopsy to be completed as necessary in the pathologist’s judgment:

[ ]	With no limitations	[ ]	Except that the following limitations are to be observed:

Part 6. Removal and Retention of Organs:

Explanation: One or more organs must be removed from the body during the autopsy. All or part of the removed organs may be retained (saved) by the pathologist for a period of time to be determined by the pathologist.

Authorization: I authorize the pathologist to remove any organs from the body (unless limited in Part 5) and to retain all or part of these organs as deemed appropriate.

Part 7. Disposal of Organs:

Explanation: Any organ tissue removed during the autopsy and not retained (saved) by the pathologist must be disposed (discarded). No records are maintained. No ashes can be maintained for the family. No ceremony is performed.

Authorization: I authorize all or part of any organs removed from the body during the autopsy to be disposed.

Part 8.

Reports:

Explanation: The pathologist will prepare a written report in which his/her findings and conclusions are summarized. The final report will be sent to the referring DIDD center/regional office/provider agency and to the attending physician. Requests for copies of the autopsy should be directed to the referring center/regional office/provider agency.

Authorization: I authorize copies of the autopsy report to be sent to the following: the decedent’s attending physician, the decedent’s medical record at the DIDD center/regional office/provider agency, and the files of the pathologist.

Part 9.

Confidentiality:

Explanation: The content of an autopsy report is confidential. The report will be sent to only those specified in Part 8.

Part 10.

Photographs:

Explanation: The pathologist may elect to take photographs of the body or parts of the body to document certain findings. The photographs are treated with the same confidentiality as any other part of the autopsy examination and report.

Authorization: I authorize the pathologist to take such photographs which are necessary or desirable in his/her judgment.

DIDD-0599 (Rev. 9/11)

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DIDD AUTOPSY PERMIT FORM

Part 11. Attendance at Autopsy:

Explanation: One or more pathologists will be present and the attending physician(s) may be present during the autopsy. Other persons may be required to be present to assist the pathologist.

Authorization: I authorize persons whose presence is necessary or desirable, in the pathologist’s judgment, to attend the autopsy.

Part 12. Information Desired from Autopsy by Next of Kin:

Explanation: As part of our efforts to reduce the cost of medical care, a complete autopsy may not be performed as this procedure is very labor intensive. The pathologist may elect to focus on certain questions of importance and interest to the next of kin.

Inquiry: What do you, as the next of kin, wish to learn from this autopsy?

Part 13. Notification of Possible Failure of Autopsy to Define Certain Disease Processes

Explanation: An autopsy may successfully define a disease process only if it results in a change in the appearance of one or more organs. Many diseases produce electrical, submicroscopic, chemical, or other changes which cannot be detected by an autopsy examination. It is possible that the pathologist cannot reach a conclusion or answer questions of interest to the next of kin even after performance of an autopsy.

Acknowledgement: I understand that the autopsy procedure has limitations in ability to diagnose diseases and the results of the autopsy may be inconclusive.

Part 14. Additional Comments:

DIDD-0599 (Rev. 9/11)

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DIDD AUTOPSY PERMIT FORM

Part 15. Signature of Next of Kin

Statement: By my signature which follows, I state the following: I am the next of kin of the decedent identified above; I

assume custody of the body for the purpose of burial. I request a Forensic Medical pathologist to perform an autopsy on the decedent’s body. Any limitations on the autopsy procedure have been accurately recorded in Part 5. The

pathologist may remove, retain, and dispose of organs as described in Part 6 and Part 7. All parts of this permit have been reviewed with me. The autopsy procedure has been explained to me. All of my questions have been answered to my satisfaction.

Signature of Next of Kin	Date/Time
Signature of Additional Next of Kin (optional)	Date/Time
Signature of Witness/Title*	Date/Time
Signature of Second Witness*	Date/Time
(Required for Telephone Consent)

*Who may sign as a witness: Any non-related competent person, age 18 or older, including persons employed by the Department of Intellectual and Developmental Disabilities (DIDD) or DIDD provider agencies, may witness the autopsy permit.

ORIGINAL SIGNED FORM:

COPIES OF SIGNED FORM:

DIDD-0599 (Rev. 9/11)

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