WORKERS' COMPENSATION REFUSAL OF TREATMENT
DATE: ____________
EMPLOYEE: _____________________
As of the above noted date, I am notifying __________________(agency) of an injury that occurred
on(date)___________. This injury was; was not initially reported by me to my supervisor on
(date)_____________.
This injury (briefly describe condition/body part) ___________________________________,
did occur while I was employed with the _______________(agency), and while performing my
assigned duties.
At this time I have been requested by a representative of _______________(agency) to be
medically evaluated by a _______________(agency) preferred healthcare provider. However, I
decline to be medically evaluated for the above noted condition. I understand that by signing this
document any future claims regarding this injury will require a medical evaluation by the
_______________(agency) healthcare provider listed below. I also understand that should I decide
to seek medical treatment for this injury that I must immediately notify my supervisor and go to
the below listed provider:
PROVIDER: _________________________________________
ADDRESS: __________________________________________
PHONE: (_____)_________________
(NOTE: SHOULD THE CONDITION BECOME LIFE THREATENING YOU SHOULD SEEK APPROPRIATE
EMERGENCY MEDICAL CARE)
I have have not sought medical treatment for this injury from:
TREATING PHYSICIAN'S Phone Number: __________________
NAME/ADDRESS (including city & state)
______________________________________________________
______________________________________________________
STATEMENT: I have read the above information and it is a factual and true statement. I authorize
any physician, hospital or healthcare provider to release and furnish any, and all, medical records
or other information pertaining to the above listed condition.
Employee signature Supervisor/witness signature
Date _____________ Date _______________
Cape Fear Valley Medical Center
1638 Owen Drive Fayetteville, NC 28304
910 615-4000
