Mar 12, 2026 11:58 To: +16042339777 Page: 05/46 From: Foremed Medical Clinic Fax: 16043985614
Fax Server 2/23/2026 9:58:11 AM PST PAGE 4/005 Fax Server

TO:Dr. Ademiluyi COMPANY:

Wor 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 biil 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.

Ry he

| Worker last name ““siddle initial | WorkSafeBC claim number |

| HOLAND : 42647464

Bate of birtty tw maa " Rersonal health fuTAber (Be services cavatarecardy r Bate of injury (wer mm 6a) —_ ;
| 1978-09-04 : 9128549738
Bate of request (wy-mnasy—: Physiianname as:
: 2026-02-23 Dr. Ademiluyi :
By

| Chart Notes (MEDRECORDS)
Existing Chart Notes for period of time
| byvyemmdd) From 2024-01-01 to Present date :

'19953 — Submit via fax or courier within 16 business days of request In order to be paid
' Fee amount covers cast for courier if used

i — Carnet bil fea items 19904 with this fee item

"Bate courierad or faxed items sant to WorkSafeBC Gyyy-mmid) SSS Tota number of pages Ginttucing coven)

i 5 tte L :
2026-03-12 7 ; 44 7 a
Please note that the information contained in this facsimile transmission is confidential and intended for the use of the parson to
whom It is addrassed. Any copying, disclasure, dissemination, or distribution of this transmission by anyone other than the intended

recipient if prohibited, Tf you have received this transmission in error, pease noilfy the sender immediately by lAlephone and
arrangements will be mada for the retrieval of such decument at nd cost to you.

Claims Call Centre Fax Mail

Phone 604,25 1.8886 604.233.9777 WorksSafeBc

Toll-free 1.888.967.5377 Toll-free 1.888.922.8807 PO Box 4700 Stn Terminal
M-F, 8 arm. to 6 p.m. Vancouver BC V68 131

WorkSafeme, goliects infection on this fora for the purposes of administering and anforcing the Workers Compensation Aci, That Act, along with lhe
Freedom of information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of parsonai
information, camtack WorkSafeBCls FIP? Office, at PO Bax 2310 Sth Terrie, Vancaaver BC, VER 3WS, or emad Fyre Saehis hcast, OF aol
804,270. 8171,

10617 {R20/08) Page 1 of 1

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