WORK COMP REFUSAL OF MEDICAL TREATMENT OR OBSERVATION
Employee’s Name: ______________________ Date Reported: _________________
Date of Injury: ______________________ Time of Injury: ______________________
Supervisor: ______________________ Client / Location: _____________________
Witness(es):
________________________________________________________________________
Nature of Injury/Condition:
________________________________________________________________________
Description of Injury [Body Part(s) Injured]:
________________________________________________________________________
Brief Narrative Description of the Incident:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I, hereby acknowledge my refusal of medical treatment and/or observation offered to me
at the expense of Renaissance Staffing for the work-related injury I incurred on
______________________. By signing this form, I realize that I do not necessarily affect
my later eligibility for Workers’ Compensation.
I acknowledge that my supervisor(s), in good faith, have offered and made available to
me an opportunity to seek necessary medical treatment and/or observation. I am aware
that by declining medical treatment at this time, that my employer, will not be responsible
for any medical expenses or lost wages.
At a later time, I may request from my employer, via my supervisor, a medical
authorization to obtain medical treatment and/or observation for the above described
injury.
______________________
Employee’s Signature
______________________
Date
______________________
Employee Represenative/Witness
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