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DECLINATION OF TREATMENT FOR WORK RELATED INCIDENTRM0002 Rev. 8/19Risk Management Department Lincoln Public Schools (Use Blue or Black ink)Phone:4024361760 Fax:4024583276ENTIRE FORM MUST BE COMPLETED
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To fill out the declination of treatment form, follow these steps:
02
Obtain a copy of the declination of treatment form.
03
Read through the form carefully to understand its purpose and requirements.
04
Fill in your personal information, including your name, date of birth, and contact details.
05
Provide details about the treatment or medical procedures that you are declining.
06
Clarify the reasons for your decision to decline the treatment.
07
Sign and date the form to confirm your understanding and agreement.
08
Make a copy of the completed form for your records.
09
Submit the original form to the relevant healthcare provider or institution as per their instructions.
10
Keep a record of when and to whom you submitted the form.
11
Review the form periodically and update it if your decision changes.

Who needs declination of treatment for?

01
Declination of treatment forms are typically needed by individuals who:
02
- Do not wish to undergo specific medical treatments or procedures.
03
- Want to exercise their right to informed consent and have the freedom to decline medical interventions.
04
- Have ethical, religious, or personal beliefs that conflict with certain treatments.
05
- Are participating in medical research or clinical trials and choose not to receive certain interventions.
06
- Wish to have control over their medical decisions and treatment options.
07
It is important to note that the specific requirements for when and how to use declination of treatment forms may vary depending on local laws, healthcare institutions, and individual circumstances.
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Declination of treatment is a formal decision made by a patient to refuse a particular medical treatment or procedure that has been recommended by a healthcare provider.
Patients who choose to decline recommended treatments are typically required to file a declination of treatment to document their decision.
To fill out a declination of treatment, a patient must provide their personal information, details about the treatment being declined, and a signature acknowledging their understanding of the implications of their decision.
The purpose of a declination of treatment is to formally document a patient's informed choice to refuse specific medical care, ensuring that their wishes are respected and protected.
The declination of treatment form must include the patient's name, identification details, description of the treatment being declined, the date, and the patient's signature.
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