• 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.

  •  -  -
    Pick a Date
  • Clear
  •  /  /
    Pick a Date
  • Clear
  •  /  /
    Pick a Date
  •  
  • Should be Empty: