Refusal Of Medical Treatment Form PDF Details

When you are incapacitated and unable to make decisions for yourself, someone else may need to step in and make choices on your behalf. In some cases, this may involve refusing medical treatment on your behalf. If you have not already done so, it is important to create a refusal of medical treatment form. This document will identify who has the authority to refuse treatments on your behalf and can help ensure that your wishes are carried out.

In the table, there is some information about the refusal of medical treatment form. It's definitely worth making the effort to learn this before you begin filling out your document.

Form NameRefusal Of Medical Treatment Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesrefusal medical treatment form employee, patient refusal of treatment form, refusal for medical treatment form, medical refusal forms

Form Preview Example




























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


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.




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

Watch Refusal Of Medical Treatment Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .