ICBC Consent to Sharing Information

I hereby authorize

Doctors at Foremed Clinic Select your doctor

Dr. J. Mathew Dr. G. Ademiluyi Dr. S. Matic Dr. N. Dasanjh Dr. X. Huang NP S. Jassar

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

Date of Accident

I understand that the information contained in the Report can be used by ICBC in connection with my insurance claim.

ICBC Report type Pick 'standard' if you are not certain

Standard Medical Report (CL489) Reassessment Report/RCA Referral (CL489B) Extended Medical Report (CL489A)

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.

Initials

Type initials in lieu of written signature

Name:

Date of birth

Your information will be encrypted.