🔗 Linked Evidence
MIRACLE-EAR CANADA 01
📄 HOLAND_CLAIM_FILE | p.356
📄 HOLAND_CLAIM_FILE | p.356
📝 Extracted Text (OCR)
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