I hereby authorize
to submit to the Insurance Corporation of British Columbia (ICBC) the Report identified below (“Report”), which contains medical information related to a motor vehicle accident dated
I understand that the information contained in the Report can be used by ICBC in connection with my insurance claim.
A photocopy or electronic version of this authorization is as valid as the original.
I have read and understood the contents of this document and I hereby consent to the sharing of the Report with ICBC, and the use of my medical information contained therein as indicated above.
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