Mar 12, 2026 11:58 To: +16042339777 Page: 06/46 From: Foremed Medical Clinic Fax: 16043985614
Fax Server 2/23/2026 9:58:11 AM PST PAGE 5/005 Fax Server

TO:Dr. Ademiluyi COMPANY:

GigE Worker’s Authorization for Release
oer of Personal Information from Third
Parties to WorkSafeBC

WorkSafeBt requires information related to your injury and employment to manage your claim under the Workers
Cempensation 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 personai information with WorkSafeBC. If you choose not te provide your authorization or cancel jt after it is
given, wa may be unable to manage your claim,

WorkSafeSt will use this form te obtain tnformation that is relevant or potentially relevant to the managemert of
your clalm. WorkSafeBC Wilt not ask tie health care providers and employars te diseiase personal information that Is
clearly pot related to the management of your claim.

‘The Act and the Freedom of Information and Protection of Privacy Act (FIPPA) atlow WorkSafeBe to collect your
personal infarmation for the management of your cialm, WorkSafeBC will usa and disclose your personal information
in atcerdance with FIPPA, the Act, and other applicable laws, This includes disclosing information to yeur
employer(s) if there is a review or an apoeal te 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 FIFPA to collect, use and disclose
personal information, contact WorkSafesC’s Access to Information and Privacy Manager at 4p
or 604.279.8171, or PO Box 23:10 Stn Terminal, Vancouver, BC V4B 2W5.

+ To physicians, quatified practitioners, ‘medical insurers, hospitals, and health care providers, 1 authorize
disciosure of copies of records requested by WorkSafeBe containing my personal information related to my
examination, treatment, diagnestic tests, and medical history ta WorkSafeBc,

+ Te my empioyer(s), 1 authorize disclosure of copies of records requested by WorkSefeBC containing my
personal infarmatian related to my employment, work history, and earnings t WorkSafeRC for the purpose
of processing and managing my workers compensation claim,

This consent for disclosure by third pasties to WorkSefeBC is in effect from the date signed uniit cancelled In

writ!

Wank Noland, | 2026-024 06

| 9128549798

Note: Authorization is not required tor disclosure by health ‘care providers who are under direct ‘contracts for
services with WorkSefeBc,

ay {a free app} to complete this form and add your
«then visit et to upload the electronic document to your claim file,
Alternatively, you can print the form, complete & manua ty, and upload 2 phote of it on the webpage above.

Fax: 604.233.9777 (toll-free at 1.888.922.8807) | Mail: WorkSafeRC, PO Bax 4700 Stn Terminal, Vancouver, BC, VB 131
For further assistance: Claims Call Centre, 604.231.8998 (toll-free at 1.886.967.5377), M-F, @ a.m. to 6 pom.

Gow {24/04} Page 1 af £

PAGE 6/46 * RCVD AT 3/12/2026 11:59:36 AM [Pacific Daylight Tima] * SVR:FAXP21/12 * DNIS:9777 * CSID:16043985614 * ANI:6043985614 * DURATION (mm