[Code of Federal Regulations]
[Title 42, Volume 1]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR37.204]

[Page 132-133]
 
                         TITLE 42--PUBLIC HEALTH
 
    CHAPTER I--PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN 
                                SERVICES
 
PART 37--SPECIFICATIONS FOR MEDICAL EXAMINATIONS OF UNDERGROUND COAL MINERS--Table of Contents
 
                           Subpart--Autopsies
 
Sec. 37.204  Procedure for obtaining payment.

    Every claim for payment under this subpart shall be submitted to 
ALFORD and shall include:
    (a) An invoice (in duplicate) on the pathologist's letterhead or 
billhead indicating the date of autopsy, the amount of the claim and a 
signed statement that the pathologist is not receiving any other 
specific compensation for the autopsy from the miner's widow, his 
surviving next-of-kin, the estate of the miner, or any other source.
    (b) Completed PHS Consent, Release and History Form (See Fig. 1). 
This form may be completed with the assistance of the pathologist, 
attending physician, family physician, or any other responsible person 
who can provide reliable information.
    (c) Report of autopsy:
    (1) The information, slides, and blocks of tissue required by this 
subpart.
    (2) Clinical abstract of terminal illness and other data that the 
pathologist determines is relevant.
    (3) Final summary, including final anatomical diagnoses, indicating 
presence or absence of simple and complicated pneumoconiosis, and 
correlation with clinical history if indicated.

[[Page 133]]

                                Figure 1

              U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

       Public Health Service--National Coal Workers' Autopsy Study

 Consent, Release, and History Form Federal Coal Mine Health and Safety 
                               Act of 1969

    I, ------------------, (Name) ------------ (Relationship) of ------
------------, (Name of deceased miner) do hereby authorize the 
performance of an autopsy (------------------) (Limitation, if any, on 
autopsy) on said deceased. I understand that the report and certain 
tissues as necessary will be released to the United States Public Health 
Service and to ------------------ (Name of Physician securing autopsy)

I understand that any claims in regard to the deceased for which I may 
sign a general release of medical information will result in the release 
of the information from the Public Health Service. I further understand 
that I shall not make any payment for the autopsy.

                    Occupational and Medical History

    1. Date of Birth of Deceased ------------. (Month, Day, Year)
    2. Social Security Number of Deceased ------------------.
    3. Date and Place of Death ------------, (Month, Day, Year) --------
---------- (City, County, State).
    4. Place of Last Mining Employment:
Name of Mine____________________________________________________________
Name of Mining Company__________________________________________________
Mine Address____________________________________________________________
    5. Last Job Title at Mine of Last Employment
(e.g., Continuous Miner Operator, motorman, foreman, etc.)
    6. Job Title of Principal Mining Occupation (that job to which miner 
devoted the most number of years)
                                                   (e.g., Same as above)
    7. Smoking History of Miner:
    (a) Did he ever smoke cigarettes? Yes
No______________________________________________________________________
    (b) If yes, for how many years?------------
Years.
    (c) If yes, how many cigarettes per day did he smoke on the 
average?----------------
                                                             (Number of)
Cigarettes per day.
    (d) Did he smoke cigarettes up until the time of his death? Yes ----
-- No ------
    (e) If no to (d), for how long before he died had he not been 
smoking cigarettes?
    8. Total Years in Surface and Underground Employment in Coal Mining, 
by State (If known) ------, (Years) ------------ (State).
    9. Total Years in Underground Coal Mining Employment, by State (If 
known) ------, (Years) ------------ (State).
________________________________________________________________________
                                                             (Signature)
________________________________________________________________________
                                                               (Address)
________________________________________________________________________
                                                                  (Date)
Interviewer:____________________________________________________________