I, am attending Dr. in regards to a motor vehicle accident that occurred on Please add period to complete this sentence.

  I hereby AUTHORIZE my physician to submit to the Insurance Corporation of British Columbia (ICBC) any of the the Reports identified below ("Report"), which contain medical information related to the motor vehicle accident referenced above. I understand that the information contained in these Reports can be used by ICBC in connection with my insurance claim.

  I hereby DO NOT AUTHORIZE my physician to submit the Report identified below ("Report") to the Insurance Corporation of British Columbia (ICBC). I understand that this information may still be released in the future pursuant to a request by ICBC under Section 28 or Section 28.1 of the Insurance (Vehicle) Act.

This document refers to the following ICBC reports:
        Standard Medical Report, CL489
        Extended Medical Report, CL489A
        Reassessment Medical Report, CL489B

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 to the sharing of the Report with ICBC, and the use of my medical information contained therein, as indicated above.



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