Alaska Most Form Medical Orders For Scope Of Treatment Page 3
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2
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4Brief Summary of Medical Condition and Rationale for these orders:
E
Check
__________________
One
Condition and orders discussed with:
_____________________________________________________________________ (Name)
_____________________________________________________________________ (Phone)
Patient
Parent of Minor
Health Care Agent appointed by person (POA for Health Care) as designated in POA or Advanced Directive
Court-Appointed Guardian
Health Care Surrogate: _______________________
Signatures for Orders
_____________________________________MD/DO/ANP/PA
Date: ________________
_____________________________________MD/DO/ANP/PA (Printed Name) Phone: _______________
HIPAA permits disclosure of ‘MOST form’ to other Healthcare Professionals as necessary
Additional Information
F
YES
NO
UNKNOWN
Advance Directive (Living Will)
YES
NO
UNKNOWN
Organ and Tissue Document of Gift
YES
NO
UNKNOWN
Appointed Health Care Agent
YES
NO
UNKNOWN
Court-appointed Guardian
YES
NO
UNKNOWN
Health Care Surrogate available
YES
NO
UNKNOWN
Comfort One orders signed
YES
NO
UNKNOWN
Other ______________________________
G
1) Name and Contact Information for Primary Health Care Agent/ Guardian/ Surrogate
____________________________________________________ (Name)
____________________________________________________ (Relationship)
____________________________________________________ (Phone)
2) Name and Contact Information for Additional Health Care Agent/ Additional Surrogate
____________________________________________________ (Name)
____________________________________________________ (Relationship)
____________________________________________________ (Phone)
June 2011
Page 3 of 2
This MOST form must accompany person when transferred or discharged.
Alaska MOST Task Force
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