Refusal Of Medical Treatment Form – Fill Out and Use This PDF

Updated: Nov 9, 2026

The Refusal of Medical Treatment form is a document that allows employees to formally decline medical care for an injury received while at work, despite being offered such care by their employer. This form not only documents the employee's decision to forgo medical treatment at the time of the injury but also serves as a reminder of their right to request medical care in the future should their condition change. Importantly, signing this form does not waive the employee's rights under workers' compensation laws, including the protection provided by receiving a claim form DWC-1.

To ensure your rights are protected while making informed decisions about your health care after a workplace injury, consider carefully filling out the Refusal of Medical Treatment form. Click the button below to proceed.

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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.

Question	Answer
Form Name	Refusal Of Medical Treatment Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	patient refusal of treatment form, work injury refusal for care form, refusal of medical treatment form, printable refusal of medical treatment form

How to Fill Out Refusal of Medical Treatment Form

Refusal of Medical Treatment Form at a glance

What it is: Refusal of Medical Treatment Form, a notice of injury and refusal of medical care, for an employee who has been offered the opportunity to have medical care for the stated injury by the employer.

Who signs: Employee's Signature / Firma de empleado, with Date / Fecha. Supervisor's or Foreman's signature / Firma de supervisor o mayordomo, with Date / Fecha. Witness Signature or Name, with Date.

A filled-in Refusal of Medical Treatment Form example: an employee refuses care for a hand injury

Refusal of Medical Treatment Form example filled out, example: an employee refuses care for a hand injury — Maria Sample, an employee, fills out the Refusal of Medical Treatment Form. She declines medical care for a hand injury that happened at 9:30 am, and her supervisor signs. The picture shows the filled form; its names and figures are sample values. The injury happened on 03/14/2026 and the employer learned of it at 10:00 am the same day, so the later date boxes hold 03/14/2026.

How to fill out Refusal of Medical Treatment Form, box by box

Employee, injury and time

Enter the Employer Name, Phone, Today's Date, Employee, Social Security, Department, Date of Injury, Time, Date employer first knew of injury, Time /Hora, and describe the injury and part of body affected.

Refusing medical care

The employee states: I feel as though I do not require medical care at this time.

Should the employee feel the need to have care, the employee will immediately report to the employer's office to request medical care.

The employee understands this is the obligation under the California Labor Code 4600.

Signing this statement only acknowledges that the employee has been given the opportunity to be examined and treated and in no way waves the right under worker's compensation laws.

The employee also acknowledges the employee has been given a claim form DWC-1 which protects the employee's rights.

Signatures and dates

Employee's Signature / Firma de empleado, with Date / Fecha.

Supervisor's or Foreman's signature / Firma de supervisor o mayordomo, with Date / Fecha.

Witness Signature or Name, with Date.

Sources

[1] Refusal of Medical Treatment Form (the served file; no issuer file found) (the Official source link on this page).