~~

Fax Server 2/23/2026 9:58:11 AM PST PAGE 5/005 Fax Server
TO:Dr. Ademiluyi COMPANY:

ge Worker's Authorization for Release
fics of Personal Information from Third

Parties to WorkSafeBC

WorkSafeBC requires information related to your injury and employment to manage your claim under the Workers
Compensation Act (the Act). Workers’ Compensation Appeal Tribunal (WCAT) may also require information if there is
an appeal related to your claim. This form is your permission for health care providers and any employer to share
your personal information with WorkSafeBC. If you choose not to provide your authorization or cancel it after it is
given, we may be unable to manage your claim.

WorkSafeBC will use this form to obtain information that is relevant or potentially relevant to the management of
your claim. WorkSafeBC will not ask the health care providers and employers to disclose personal information that is
Clearly not related to the management of your claim,

The Act and the Freedom of Information and Protection of Privacy Act (FIPPA) allow WorkSafeBC to collect your
personal information for the management of your claim. WorkSafeBC will use and disclose your personal information
in accordance with FIPPA, the Act, and other applicable laws, This includes disclosing information to your
employer(s) if there is a review or an appeal to WCAT as this disclosure is required by law.

Please contact your claims representative if you have a question about how the personal information will be used to
manage your claim. If you have a question about WorkSafeBC’s authority under FIPPA to collect, use and disclose
personal information, contact WorkSafeBC’s Access to Information and Privacy Manager at {py cimart
or 604.279.8171, or PO Box 2310 Stn Terminal, Vancouver, BC V6B 2WS.

LOM,

Work

’s informa

Worker's last name | First name | Middle initial | WorkSateBe claim nur
Holand Mark \T 42647461

ere cme eterno ~ = ee

| Address tine T City Province | Postal code
311-318 Agnes St New Westminster BC V3L 0J3

[Phone umber : i Bate of bith (yyyyemm-dd}

236-994-3376 | 1978-09-04

Authorizatio 5} far et

[ + To physicians, qualified practitioners, medical insurers, hospitals, and health care providers, 7 authorize

disclosure of copies of records requested by WorkSafeBC containing my personal information related to my
| examination, treatment, diagnostic tests, and medical history to WorkSafeBC.

* To my employer(s), 1 authorize disclosure of copies of records requested by WorkSafeBC containing my
personal information related to my employment, work history, and earnings to WorkSafeBC for the purpose
rocessing and managing my workers compensation claim.

This consent for disci to WorkSafeBC is in effect from the date signed until cancelled in ;

Personal health auniber (oc Sewe

2026-02-06 | 9128549738 |

Date signed (yyyr-re

Haw Te
Uptoasin g 6

Subie vou

ine is isthe quickest method! Use /, : {a free app) to complete this form and add your
electy we, then visit worksafeas,cani cis ‘to pieced the electronic document to your claim file.
Alternatively, you can print the form, complete it ancaly, and upload a photo of it on the webpage above.

Fax: 604.233.9777 (toll-free at 1.888.922.8807) | Mail: WorkSafeBC, PO Box 4700 Stn Terminal, Vancouver, BC, V6B 131
For further assistance: Claims Call Centre, 604.231.8888 (toll-free at 1.888.967.5377), M-F, 8 a.m. to 6 p.m.

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