sa FE BC Web Mailing Address Fax Call Centre
www.WorkSafeBC.com PO Box 4700 Stn Terminal 604 233-9777 604 231-8888

Vancouver BC V6B 1J1 1 888 922-8807 1 888 967-5377
WORKING TO MAKE A DIFFERENCE

February 23, 2026

DR. ADEMILUY| GBOGBOADE ADEBO
FOREMED CLINIC

420 COLUMBIA ST

NEW WESTMINSTER BC V3L 1B1

To the Health Care Provider:

REGARDING: MARK HOLAND

DATE OF INJURY: January 12, 2026

PERSONAL HEALTH CARE NUMBER: 9128549738
DATE OF BIRTH: September 04, 1978
WORKSAFEBC CLAIM NUMBER 42647461

The above-named worker has filed a claim for compensation for an injury sustained on
January 12, 2026.

Please provide a copy of all previous chart notes relating to migraines & bilateral ears
that covers the date from January 1%, 2021 to current date. Please include copies of
all radiological, consultation reports, results of tests that may have been
undertaken such as EMG, MRI, X- Rays, U/S, CT scans etc.

It is important that only medical information relevant to the above request is
provided.

Under both the Workers Compensation Act and the 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
attached.

Enclosed is the Request for Severed Physician/Psychiatrist Records. The form includes
the appropriate code and fee items as per the fee structure agreed on by your
association and WorkSafeBC.

Use the attached request form as your cover sheet. This will ensure a timely submission
to the worker's claim file. Include the worker’s name and claim number on all pages
submitted.

PLEASE INCLUDE CLAIM OR ACCOUNT NUMBER IN ALL CORRESPONDENCE

Workers’ Compensation Board of British Columbia
D0280 SEP 2020 - MD - M