Refusal of Medical Treatment or Observation Form

Health & Wellness
Safety & OSHA

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I acknowledge my refusal of medical treatment and/or observation offered and made available to me by my employer, XYZ Company, for the work-related injury I incurred on <date>. By signing this form, I understand this will not affect my eligibility for Workers’ Compensation. At a later time, I may request a medical authorization to obtain medical treatment and/or observation for the above described injury.

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