Mar 12, 2026 11:58 To: +16042339777 Page: 05/46 From: Foremed Medical Clinic Fax: 16043985614
Fax Server 2/23/2026 9:58:11 AM PST PAGE 4/005 Fax Server

TO:Dr. Ademiluyi COMPANY:

Request for Severed
Physician/ Psychiatrist Records

Please use this form as your submisston cover sheet to ensure payment for the requested information.
This is not an invoice. You must bill separately for the items submitted with this cover sheet.
Write your patient's name and WorkSafe8C claim number on each page submitted with this request.

Worker last name Middle initial | WorkSafeBC claim number |
| HOLAND : ‘42647461, :
“Bate of birth iywymmse) | Personal health munber 13¢ services cerspcareconay "Gate of injury cryy-am-on ‘

1 1976-09-04
ey
02-23

26-01-12

Y¥Y YEH

) Existing Chart Notes for period of time
 Gyvy-mm-ddp From 2021-01-01 to Present date :
Comments Please provide all clinical records re: migraines, bilateral ears. Thank you. i

i 19953 — Submit via fax or courier within 10 business ‘days of requast in order to be paid
i ~ Fee amount covers cost for courier if used
: — Cannot bill fee items 19904 with this fee item i

ems sant to WorkSafeBC tyyyy-rin-id)
2026-03-12

“Total number of pages Gnttucing coumy
44

Please note that the information contained in this facsimile transmission is confidentiat and intended for the use of che parson to
whom if is addressed. Any copying, disclosure, dissemination, or distribution of this transmission by anyone other than the intended

recipient id prohibRed, Tf you have received this trartsiissior in error, please notify Lhe sender inrrehately by lelephote and
arrangements wilf be miade for the retrieved of such decument at no cost fa you.

“Bate coutiered or faxed

Claims Call Centre Fax Mail

Phone 604,231.8888 604.233.9777 WerkSafeBc

Tail-free 1.888.967.5377 Toll-free 1.888.922.8807 PO Box 4700 Str Terminat
M-F, 8 a.m. to 6 p.m. Vancouver BC V6B 131

WorkSafe collects infommatian on this for for the purgosesi of administering and enforcing the Werkers Compensatian Act, ‘That Act, along with the
Freedom of information and Protection af Privacy Act, constitutes the authority to collect such information. Tc ieaen more about the collection of personal
inforroatian, camtack WorkSafeSt'y FIP? Oifiew, at PO Box 2319 Sth Terminal, Vancouver BC, VOB 3WS, or emall FLEE! moat, OF mit

B04 278.8104.

10037 {R20/08) Page 4 of 4

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