Work Comp Declination of Medical Treatment Employee Name(Required)Select NameAbigail PeeryAlicia HerbstAllie KisterAllison McAteeAlyssa ZahnAmanda CaldwellAndrew FaulknerAndrew SniderAndrew WeaverAriel GrayArika BallengerAshley BeardBrad HahnBrad WeissBreanna BensonBrett HortonBrianna AsherBrooke NicholsBryce StewartCaleb GoveroChealsa LongChloe MoonChloe RoachChristopher HooverClayton MollColin HedrickDale HamptonDale WhitenerDaniel KempDanny ParishDavid StarkDawson KoenDerrick CarltonDustin TateDylan RiceEllen MurphyEmily GrassEmily HerbstEmily SchumerEmma CollinsErika RobinsonHaley WeberHalle ArbeitmanJacob GoodeJackie WagganerJason DossJason NoelJason SitzesJeanne HochstatterJenna BoyerJennifer PriceJessica ChitwoodJessica SagoJohn ColwellJorden FliegJoseph StepputatJoseph WingbermuehleJosh AkersKathrine DonaldsonKatie ShawKelleeta WisdomKent ColemanKevin MeseyKimberly FeldhakeKristin MotsingerKristy HalterKurtis StevensKyla NicholsKyle GartnerKylie WoffordKyleigh PrzygodaLaurine DennisLeah CoppawayLeah ThomasLewis MillerLillian SmithLucas KramerMaddy GartnerMaria JonesMarie BethelMark EarnestMatthew EggersMatthew McElrathMatthew PeeryMatthew ShortMichael PolitteMichael DodsonNathan StaffordNicholas MillsNick JenningsPaige ClarkPhillip SchiffmanRandell HeadyRebecca MillerReece KreitlerReese GibsonRenee McClureRiley ColemanRoger StevensRyan HillSamantha FrascaSamuel HerbstSarah SundhausenStefanie TalarskiSteven DickeyTamera KahlerTammy ZookTanner SundhausenTaylor CopelandTeralyn CoxTerry LeachTiffany HensonToby BrownTrina SchmitzZackary ShoemakerZach BrooksZachary Gallaher This field is hidden when viewing the formEmployee Email(Required)Social Security Number(Required)Title(Required)Date of Injury(Required) MM slash DD slash YYYY Who Authorized The Medical Treatment That You Are Declining??(Required)Select NameJason NoelDavey MillerKristy HalterRenee McClureDustin TateSteven DickeyLaurine DennisMichael DodsonJorden FliegJessica ChitwoodDerrick CarltonColin HedrickNick Jennings This field is hidden when viewing the formTreatment Authorized By Email(Required)Location of Incident(Required) Street Address City State / Province / Region ZIP / Postal Code Body Part Injured(Required)Additional Remarks:Treatment Declination(Required)I am declining my employer’s offer of authorized medical treatment to cure and relieve the effects of the injury I am claiming to have sustained at work on the date entered above. I understand that by declining my employer’s offer of medical care, any treatment I obtain on my own will be at my own expense. I also understand that if I reconsider and am interested in receiving authorized medical care, I must advise my employer as soon as possible. I agree to the Treatment Declination statement aboveEmployee Signature(Required)
