2026-02-09 Worker Letter Authorization Form 69W1 Required for Medical Records

Claims
WORK BC Mailing address: PO Box 4700 Stn Terminal, Vancouver BC V6B 1J1
Phone 604.231.8888 | 1.888.967.5377 | Fax 604.233.9777 | worksafebc.com

February 09, 2026

MARK HOLAND Your WorkSafeBC Claim number | 42647461
UNIT 311 318 AGNES ST
NEW WESTMINSTER BC V3L 0J3 Your Customer Care number 93970460601

Date of your injury 2026-01-12

Dear MARK HOLAND:

We are reviewing your claim and need your help to gather additional information to proceed. We
kindly ask that you complete and submit our Worker’s Authorization for Release of Personal
Information from Third Parties (form 69W1). This form gives us permission to ask for information
relevant to your claim. This includes — but is not limited to — information from physicians, medical
treatment providers, medical insurers, hospitals, and any employer.

How to complete and submit your form

The quickest way to complete and submit the form is to upload it online. Visit
worksafebc.com/69W1-upload to download a fillable pdf. Follow the directions on that page to
complete the form and upload it to your claim.

You may instead, complete and sign the enclosed paper form. Your completed paper form may be
sent to us by one of the following means:

e Take a picture of the completed form or scan it. Visit worksafebc.com/69W1-upload to
submit the electronic document to your claim file.

e Fax the completed form to us at 604.233.9777, or toll-free at 1.888.922.8807.

e Mail the completed form to the address provided at the top of this letter.

In addition, if you have been treated in the last two years by any doctor other than your current
doctor, please provide the doctor’s name, address, and phone number on a separate sheet of paper.
Please be sure to include your name and claim number.

If you have any questions or would like to discuss your claim, please call us at 604.231.8888, or toll-
free 1.888.967.5377, Monday through Friday, anytime between 8 a.m. and 6 p.m., Pacific Time.

Sincerely,

Claims team
WorkSafeBC

Copies to:

Enclosure(s): Worker’s Authorization for Release of Personal Information from Third Parties (69W1)

D0106-M-CC-R22/03