Montreal Cognitive Assessment (MOCA) - bhsol …

1 DesignationMontreal Cognitive Assessment ( moca )VAC 762e (2010-06)SignatureDate (yyyy-mm-dd)Ce formulaire est disponible en fran namesFamily nameFile when client's personal information is collected under the authority of theVeterans Health Care Regulationsfor the purpose of administering benefits andservices. Provision of the information is on a voluntary basis. Any personal information recorded on this form is accessible by the individual to whom it personal information collected and used is protected from unauthorized disclosure by thePrivacy Actprovides the client with a right toaccess his or her own personal information which is under thecontrol of the Department.

2 ThePrivacy Actalso affords the client the right to challenge theaccuracy and completeness of his or her personal information and have it amended as client may request a copy of this form by writing to the Access to Information and Privacy Coordinator's Office, Veterans Affairs Canada, PO Box 7700,Charlottetown, PE, C1A 8M9 and by quoting Personal Information Bank No. VAC PPU 020 and/or VAC PPU and postal codeDate of birth(yyyy-mm-dd)Date of Assessment (yyyy-mm-dd)