FAX Cover Sheet Date: CONFIDENTIAL To: Central Fax - MOST & ACP Record Fax: 604-587-3748 From: Phone: You should receive _____ page(s) including this cover sheet. Attached please find: MOST ACP Record Quality Assurance check complete: Patient Legal Name and PHN clear (label preferred) Section 1: Code Status - check one box only Section 2: MOST Designation (M or C category) - check one box only Section 3: OPTIONAL Section 4: MOST Order entered as per:
Conversation/Consensus - document full name and relationship to patient
Physician Assessment and... - check one box only
Supporting Documentation - check all that apply Date Completed, Physician Name, Signature, MSP, and Contact Number Documents provided by:

Name of practice/Doctor/Site: Phone: Address: Fax: This message is intended only for the use of the individual or entity to which it is addressed, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. Any other distribution, copying or disclosure is strictly prohibited. If you have received this fax in error, please notify us immediately by telephone and destroy this fax.