I acknowledge that I have been informed of the procedures for obtaining medical treatment for the work- related injury or illiness described above. I have been offered medical treatment and understand my right to receive such care.
By signing below, I am voluntarily declining medical treatment at this time. I understand that:
• I am fully responsible for soeking any further medical attention related to this injury or iliness.
• I will be personally responsible for any expenses incurred as a result of obtaining such treatment.
• State law permits my employer to request a drug screening within 24 hours of reporting a workplace injury.
•Refusing medical treatment and/or failure to comply with drug screening requirements may impact my eligibility for benefits under the Workers' Compensation Act
