Request for Non-Contracted/Out-of-
Province
Provider Records

Important: If you do not have a payee number with WorkSafeBC, please contact our Procurement Services

department at 604.276.3344.

Please use this form as your fax 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 WorkSafeBC claim number on each page submitted with this cover sheet.
Worker's last name First name Middle initial WorkSafeBC claim number
HOLAND MARK 42647461
Date of birth (yyyy-mm-dd) Personal Health Number (8¢ Services Card/CareCard)

1978-09-04 9128549738
Date of request (yyyy-mm-dd) Provider’s name
2026-03-02 Amplifon (formerly Miracle-Ear Canada)

Chart notes (MEDRECORDS) for dates (yyyy-mm-dd)

From: 2021-01-01
To: PRESENT

1136896 — Submission of requested records

Date sent to WorkSafeBC (yyyy-mm-da)

Total number of pages (including this cover sheet)

Sent from fax number (include area code)

Sent to fax number (include area code)

Please note that the information contained in this facsimile transmission is confidential and intended for the
use of the person to whom it is addressed. Any copying, disclosure, dissemination, or distribution of this
ransmission by anyone other than the intended recipient is prohibited. If you have received this transmission in

error, please notify the sender immediately by telephone, and arrangements will be made for the retrieval of such

document at no cost to you.

Claims Call Centre Fax

Phone 604.231.8888 604.233.9777

Toll-free 1.888.967.5377 Toll-free 1.888.922.8807
M-F, 8 a.m. to 6 p.m.

Mail

WorkSafeBC

PO Box 4700 Stn Terminal
Vancouver BC V6B 1)1

WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along with the
Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of personal
information, contact WorkSafeBC’s FIPP Office at PO Box 2310 Stn Terminal, Vancouver, BC, V6B 3W5, email FIPP@worksafebc.com, or call

604.279.8171.

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