To: +16042339777 Page: 03/46 From: Foremed Medical Clinic

Fax Server 2/23/2026 9:58:11 AM PST PAGE 2/005 Fax Server
TO:Dr. Ademiluyi COMPANY:

SAFE BC Web WorkSeteBs, Maiing Address Fax Cal Centre
eBGCOM ory tox 4700 St'Tentinal 604 239-9777 04 20-88

WORKING TO MAKE & DIFFERENCE Vancowwer SS Vath 1h 1 BBO 922-6007 1860 967-6377

February 23, 2026

DR. ADEMILUYI

FOREMED CLINIC

420 COLUMBIA ST

NEW WESTMINSTER BC V3b 181

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.

Plaase provide a copy of all previous chart notes relating to migraines & bilateral ears
that covers the date from January 1%, 2021 ta 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.

itis important that only medicat information relevant to the above request is
provided.

Under both the Workers Compensation Act and the Freedom of information and
Protection af 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 ihis medical informatio is
attached.

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

Use the allached 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
subrnitted.

PLEASE INCLUDE CLAIM OR ACCOUNT NUMBER IN ALL CORRESPONDENCE
rd of British Columbia

Workers’ Conipe:
$k

Fax: 16043985614

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