Secure Case Intake Request

Organization Name

Primary Contact Name*

Organization Type Organization TypeFuneral HomeHospitalHospiceNursing FacilityMedical Examiner/CoronerOrgan Procurement OrganizationLaw EnforcementOther

Title/Position

City, State

Email Address

Office Phone*

Mobile Phone*

Preferred Method of Contact Preferred Method of ContactPhone CallText MessageEmail

Decedent Name (If Available)

Date of Death

How quickly do you need APEX to respond? How quickly do you need APEX to respond?Immediate (ASAP)Within 1 HourWithin 2 HoursScheduled PickupOther

Requested Pickup Date

Requested Pickup Time

Current Location of Decedent*:

Service Needed Please select all that apply. Service Needed Please select all that apply. First Call / Removal Local Transportation Long-Distance Transportation Refrigerated Storage Embalming Restorative Care Dressing & Casketing Organ/Tissue Donor Support Autopsy Support Airport Shipping / Receiving Ship-Out Preparation Other

Confirmation Confirmation I certify that I am authorized to request mortuary services on behalf of my organization. I understand that submission of this form does not constitute final authorization for services. An APEX representative will contact me to verify all information before services begin. I acknowledge that any protected information submitted through this portal will be handled in accordance with applicable privacy laws and APEX Deathcare Services LLC policies.