Employee Medical Care Refusal And Dwc1 Receipt printable pdf download

Employee Medical Care Refusal And Dwc1 Receipt

Employee Medical Care Refusal and DWC1 Receipt

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On ________________________

I sustained an injury to the following body

part/s_____________________________. I was offered medical care but I have refused.

My signature below documents my refusal of medical attention and acknowledges that I

was provided a DWC1 Workers Compensation Claim Form and Notice of Potential

Eligibility by my employer on the date noted. Should I need medical attention at a later

date I will notify my employer immediately.

________________________________

______________________________

Date

Signature

________________________________

Print Name

Spanish

El Dia ________________________ Yo me lesione en la/s siguiente parte/s del

cuerpo_____________________________ Me ofrecieron tratamiento medico pero no

acepte. Mi firma abajo indica que no acepte atencion medica y que he recibido la forma

DWC1 Workers Compensation Claim Form and Notice of Potential Eligibility de mi

empleador en la fecha indicada. Si en el futuro necesito tratamiento medico le notificare a

mi empleador inmediatamente.

________________________________

______________________________

Date/Fecha

Signature/Firma

________________________________

Print Name/ Nombre en letra de molde

Employee Medical Care Refusal And Dwc1 Receipt