2026-03-03 Provider Letter (Non-Contracted) Request Medical Records 10D8 Enclosed

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

March 03, 2026

MIRACLE-EAR CANADA, LTD.
(203A- SURREY LOCATION)

SUITE 102-5600 EXPLORER DRIVE
MISSISSAUGA ON L4W 4Y2

To the Health Care Provider:

Client’s name MARK HOLAND

Client’s date of birth September 04, 1978

Client’s Personal Health number 9128549738

WorkSafeBC Claim number 42607461

Date of injury January 12, 2026

The above-named worker has filed a claim for compensation for an injury sustained at work.
Information we have on file indicates you have provided treatment to this worker. Please provide
copies of your chart notes relating to this worker’s LEFT and RIGHT EARS and MIGRAINES from
JANUARY 15, 2021 to PRESENT, including copies of all audiology and consultation reports.

Under both B.C.’s Workers Compensation Act and its Freedom of Information and Protection of
Privacy Act, WorkSafeBC is given authority to receive all medical information pertaining to this
worker that is considered necessary for the adjudication of the claim.

A copy of the worker’s authorization for the release of this medical information is enclosed, along
with a Request for Non-Contracted/Out-of-Province Provider Records. The latter form includes the
fee item code to bill WorkSafeBC for this service. Use the request form as your fax cover sheet. This
will ensure a timely submission to the worker’s claim file. Include the worker’s name and claim
number on all information you submit.

To be paid for your submissions, you must have a payee number from WorkSafeBC. If you do not
already have a payee number, reach out to our Procurement Services department at 604.276.3344
or toll-free at 1.844.276.3344.

For payment inquiries, contact Payment Services at 604.276.3085 or toll-free at 1.888.422.2228.

Thank you for your earliest attention to this matter. If you have questions, call me at 250.881.3481,
extension 3481, or toll-free at 1.888.967.5377, extension 3481.

D0892-M-MD-R24/03