FRSA - Self Insurers Fund
WORK COMP REFUSAL OF MEDICAL TREATMENT WITH CONSENT TO DRUG TESTINGEmployee'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 (insured name) for the work-related injury I incurred on (date of injury). By signing this form, I realize that I do not necessarily affect my later eligibility for Workers' Compensation.I acknowledge that mysupervisor(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 my employer will not be responsible for any medical expenses or lost wages.It is also my understanding that this is a Drug Free Workplace, and a mandatory drug screening after a work-related accident is required. At a later time, I may request from my employer, via my supervisor, authorization to obtain medical treatment and/or observation for the above described injury.Employee's SignatureEmployee Representative/WitnessDateDate-8299176398REFUSAL TO CONSENT TO A DRUG TESTI, _______________________________, refuse to submit for mandatory drug testing/screening.__________________________ _________________________________ (Print Name) (Signature) (Date)__________________________ _________________________________ -7883296194(Witness Print Name) (Witness Signature) (Date) ................
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