Mar 12, 2026 11:58 To: +16042339777 Page: 06/46 From: Foremed Medical Clinic Fax: 16043985614
Fax Server 2/23/2026 9:58:11 AM PST PAGE 5/005 Fax Server

TO:Dr. Ademiluyi COMPANY:

mgs Worker's Authorization for Release
e of Personal Information from Third
Parties to WorkSafeBC

WorkSafeSc requires information related to your injury and employment to manage your claim under the Workers
Cempensation Act (zhe Act). Workers’ Compensation Appeai Trounai (WCAT) may alse require information if there is
an appeal related to your claim. This form is your permission for health care providers and any employer to share
your personai information with WorkSafeBC. If you choase nat te provide your authorization or cancet it after it is
given, we may be unable to manage your claim.

WorkSafest will use this form te obtain information that is relevant or potentiatly relevant to the management of
your claim. WorkSafeBc wilt not ask the health care providers and employers te disciase persona Information that is
clearly pot related to fhe management of your claim.

The Act and Che freedom of Information and Protection of Privacy Act (PIPPA) allow WorkSafeSe to collect your
personal information for the management of your cialm. WorkGafeBC will usa and disclose your personal information
in accordance with FIPPA, the Act, and other applicable laws, This includes disclosing information to your
employer(s) if there is a review or an apoeal te WCAT as this disclosure is required by law.

Please contact. your claims representative if you have a question about how the personal information will be used to
manage your clair. If you have a question about WorkSafeBC’s authority under FIPPA to collect, use and disclose
personal information, contact WorkSafeBC’s Access to Information and Privacy Manager at fipint st

or 604.279.8171, or PO Sox 2310 Stn Terminal, Vancouver, BC V4B 2W5.

! + Ta physicians, qualified pract: toners, ‘medical insurers, hospltats, and health ¢ care 2 providers, fi ‘authorize

| disciosure of copies of records requested by WorkSafeBC containing my personat information related to my

| examination, treatrnent, diagnostic tests, and medical history to WorkSafeBc.

| « To my empinyerts), | authorize disclosure of copies of records requested by WorkSafeBC containing my
personal information related to my employment, werk history, and earnings to WorkSafeBc for the purpose
Of processing and managing my workers compensation calm.

‘This consent for disclgsure by third partles to WorkSefeBc fs in effect from the date signed untit cancelled jn

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Meade No banc é 2026-024 -08 | 9128649798

Note: Authorization | is not required for disclosure by health ‘care ‘providers who are under direct ‘contracts for
services with WorkSefeac.

vt

is the quickest method! Use + (a free app) to cornplete this form and add your
, then visit we Ra aE Pa to upload the electronic document te your claim file.
Alternatively, you can print the form, complete i manualty, and upload e photo of it on the webpage above.

Fax: 604.233.9777 (toll-free at 1.988.922.8907) | Mail: WorkSafeBC, PO Bax 4700 Stn Terminal, Vancouver, &C, VB 131
For further assistance: Cigims Call Centre, 604.231.8888 (toll-free at 1.888.967.5377), M-F, 8 a.m. te 6 Bm.

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