WoRK BC Request for Severed

Physician/Psychiatrist Records

Please use this form as your submission 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 request.

Worker's information

Worker last name First name Middle initial WorkSafeBC claim number
HOLAND MARK 42647461

Date of birth (yyyy-mm-dd) Personal health number (BC Services Card/CareCard) Date of injury (yyyy-mm-dd)

1978-09-04 9128549738 2026-01-12

Date of request (yyyy-mm-dd) Physician name

2026-02-23 Dr. Ademiluyi

Request item

Specific block of Severed Chart Notes (please redact and exclude non-claim related information)

Chart Notes (MEDRECORDS)
Existing Chart Notes for period of time
(yyyy-mm-dd) From 2021-01-01 to Present date
Comments Please provide all clinical records re: migraines, bilateral ears. Thank you.

Fee item

For submission of Severed Chart Notes (please redact and exclude non-claim related information)

19953 — Submit via fax or courier within 10 business days of request in order to be paid
— Fee amount covers cost for courier if used
— Cannot bill fee items 19904 with this fee item

Date couriered or faxed items sent to WorkSafeBC (yyyy-mm-dd) Total number of pages (including cover)

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 transmission 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 Mail

Phone 604.231.8888 604.233.9777 WorkSafeBC

Toll-free 1.888.967.5377 Toll-free 1.888.922.8807 PO Box 4700 Stn Terminal
M-F, 8 a.m. to 6 p.m. Vancouver BC V6B 1J1

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, or email FIPP@worksafebc.com, or call
604.279.8171.

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