Refusal Of Medical Treatment Form PDF Details

In the landscape of occupational health and legal employee rights, the Refusal of Medical Treatment form stands as a critical document. Through this form, an employee has the capacity to officially decline medical treatment or attention for an injury sustained in the workplace. The form records essential details such as the employer's name, contact information, the employee's social security number, and specifics regarding the injury such as its nature, the affected body part, and the timing of the injury occurrence and its report to the employer. Significantly, this document serves not only as a record of an employee's decision against immediate medical care but also as a testament to their understanding of their rights and obligations within the framework of the California Labor Code 4600. By signing this form, an employee acknowledges their opportunity for medical examination and treatment while affirming that this denial does not waive their rights under workers’ compensation laws. Additionally, the inclusion of the DWC-1 form with the refusal document ensures that an employee's rights are further protected, highlighting the careful balance between employee autonomy and legal protection within the workplace.

QuestionAnswer
Form NameRefusal Of Medical Treatment Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespatient refusal of treatment form, work injury refusal for care form, refusal of medical treatment form, printable refusal of medical treatment form

Form Preview Example

REFUSAL OF MEDICAL TREATMENT FORM

EMPLOYER NAME:

 

 

_

 

 

 

 

_

_

 

PHONE:

 

 

 

_

 

 

 

 

_

 

 

 

 

 

Today’s Date / Fecha de hoy______

_________________________________________

 

Employee / Empleado

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security / Seguro Social

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department / Departamento

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Injury / Fecha de Lastimadura

 

 

 

Time / Hora

 

 

 

 

 

 

 

Date employer first knew of injury / Fecha que patron supo de lastimadura

Time / Hora

Describe injury and part of body affected / Describa la lesion y la parte del cuerpo afectada

NOTIFICATION DE LASTIMADURA Y REHUSAR CUIDADO MEDICO

Amime ha dado mi patron, la

oportunidad de recibir atencion medica para la lastimadura supracirada. En este momento, no creo necesitar atencion medica. Sin embargo, si llego necesitar tal atencion me reportare inmediatamente a la oficina de la compania. Entiendo que esta es mi obligacion bajo el codigo laboral de California.

El que yo firme esta declaracion es solo en reconocimiento que se me ha dado la oportunidad de ser examinado y de recibir tratamiento y no estoy renunciando a mis derechos bajo las leyes de compensacion de tabajadores. Ademas, reconozco que he recibido la forma DWC-1 las cual protege mis derechos.

NOTICE OF INJURY & REFUSAL OF MEDICAL CARE

I,

 

have been offered the opportunity to

have medical care for the above stated injury by my employer. I feel as though I do not require medical care at this time. However, should I feel the need to have care I will immediately report to my employer’s office to request medical care. I understand this is my obligation under the California Labor Code 4600.

My signing of this statement only acknowledges that I have been given the opportunity to be examined and treated and in no way waves my right under worker’s compensation laws. I also acknowledge that I have been given a claim form DWC-1 which protects my rights.

Employee’s Signature / Firma de empleado

Date / Fecha

 

 

 

Supervisor’s or Foreman’s signature / Firma de supervisor o mayordomo

Date / Fecha

Witness Signature or Name / Firma or nombre de testigo

 

Date / Fecha

How to Edit Refusal Of Medical Treatment Form Online for Free

Having the goal of making it as simple to go with as possible, we built the PDF editor. The process of creating the refusal of medical assistance form will be uncomplicated should you comply with the following steps.

Step 1: Click the orange button "Get Form Here" on the following webpage.

Step 2: Now, you're on the document editing page. You may add information, edit current details, highlight certain words or phrases, insert crosses or checks, add images, sign the form, erase unneeded fields, etc.

The following parts are in the PDF template you'll be creating.

entering details in refusal of medical care form step 1

Remember to put down your particulars inside the area NOTICE OF INJURY REFUSAL OF, I have been offered the, My signing of this statement only, Employees Signature Firma de, Supervisors or Foremans signature, and Witness Signature or Name Firma.

Filling in refusal of medical care form step 2

Step 3: Choose the "Done" button. You can now export your PDF file to your electronic device. As well as that, you may deliver it via electronic mail.

Step 4: Make sure you stay clear of potential complications by creating as much as a couple of duplicates of the form.

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