WoRK | work fy BG) a Worker’s Authorization for Release
ai 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 fipp@worksafebc.com,
or 604.279.8171, or PO Box 2310 Stn Terminal, Vancouver, BC V6B 2W5.

Worker's information

Worker's last name First name Middle initial | WorkSafeBC claim number
Holand Mark T 42647461

Address line City Province | Postal code
311-318 Agnes St New Westminster BC V3L 0J3
Phone number Alternate contact number (optional) Date of birth (yyyy-mm-dd)

236-994-3376 1978-09-04

Authorization for disclosure

* To physicians, qualified practitioners, medical insurers, hospitals, and health care providers, I 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), I 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
of processing and managing my workers compensation claim.

This consent for disclosure by third parties to WorkSafeBC is in effect from the date signed until cancelled in

writing.

Worker's signature Date signed (yyyy-mm-dd) | Personal health number (BC Services Card/CareCard)
Wark Noland
2026-02-06 9128549738

Note: Authorization is not required for disclosure by health care providers who are under direct contracts for
services with WorkSafeBC.

How to complete and submit your form

Uploading online is the quickest method! Use Adobe Acrobat Reader (a free app) to complete this form and add your
electronic signature, then visit worksafebc.com/claims-uploader to upload the electronic document to your claim file.
Alternatively, you can print the form, complete it manually, 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 1J1
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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