Refusal of Medical Treatment

Strategic Focus Clear Vision Defined Strategy. Proven Results.

3540 E. Broad St. Store 6870#126 Mansfield, Tx 76063
Email the completed forms to claims@stratfocusllc.com or Fax to: 1 214 833 7257
ACKNOWLEDGEMENT OF REFUSAL OF MEDICAL TREATMENT

, acknowledge that I have refused to be medically evaluated for a work

.I understand that by signing this document any

future claims regarding this injury will require me to notify my supervisor immediately. I also understand that even though I do not require medical treatment for this injury, I still must adhere to a mandatory drug screen.
I,________ , acknowledge that I have refused to be medically evaluated for a work related injury I sustained on_________ . I understand that by signing this document any future claims regarding this injury will require me to notify my supervisor immediately. I also understand that even though I do not require medical treatment for this injury, I still must adhere to a mandatory drug screen.
Your Name
Work Related Injury Date

Month Day Year
Date
EMPLOYEE NAME
EMPLOYEE SIGNATURE

Clear
DATE

Month Day Year
Date
EMPLOYER SIGNATURE

Clear
DATE

Month Day Year
Date
Should be Empty: