Fillable 06 Right Of Refusal Of Medical Aid TM (Cast & Crew)

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06 Right Of Refusal Of Medical Aid TM (Cast & Crew)

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2300 Empire Avenue 5th Floor Burbank California 91504 T 818.848.6022 www.castandcrew.com
ALBUQUERQUE ATLANTA BATON ROUGE BURBANK DETROIT NEW ORLEANS NEW YORK WILMINGTON
TORONTO VANCOUVER
PRODUCTION/EVENT COMPANY _____________________________
PROJECT/EVENT TITLE __________________________
This form has been given to you because you have refused or declined an initial offer of treatment
or transportation for medical treatment to a health provider.
I, hereby refuse the first aid treatment or transportation for
medical treatment to a health provider for the illness or injury incurred by me on this date .
In signing this waiver, I relieve the production/event company and Cast & Crew/CAPS from any and
all liability or damages resulting from this refusal to accept such first aid treatment.
Employee Name (Print or Type) Jo
b Title or Position
Employee Signature
Date
Supervisor Signature
Supervisor Name (printed)
Medic Signature
Medic Name (printed)
Should your
condition require further medical treatment, please contact Cast & Crew immediately at
workcomp@castandcrew.com. Please submit via email or fax the completed copy of this form to Cast
& Crew within 24 hours of knowledge of injury.
Cast & Crew Entertainment Services, LLC- Workers’ Compensation Department
Tel: 818.848.6022 Fax: 818.848.4614 workcomp@castandcrew.com
Right of Refusal of Medical Aid
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06 Right Of Refusal Of Medical Aid TM (Cast & Crew)

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Completed 27 August 2021

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