REFUSAL OF MEDICAL TREATMENT FORM

REFUSAL OF MEDICAL TREATMENT FORM

FORMULARIO DE RECHAZO DE TRATAMIENTO MEDICO

I acknowledge that I have been informed of the procedures for obtaining medical treatment for the work- related injury or illness 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 seeking any further medical attention related to this injury or illness.
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.