DECLINATION OF MEDICAL TREATMENT ______________________ has advised me to seek medical treatment for ______________________________________ at the following medical facility: (type of illness or injury) ________________________________________. I decline medical treatment at this time. I have been offered medical treatment, given a copy of the Workers Compensation form DWC-1, and understand that I may seek medical treatment from my employer’s designated medical facility listed above at a later date. If I choose to seek medical attention, I will immediately inform my employer and proceed to a Workers’ Compensation medical provider listed above or another provider within the YMCA of Silicon Valley medical provider network. Print employee’s name: ______________________________________ Employee signature and date: ______________________________________ Supervisor’s signature and date: ______________________________________ ***For more information on participating Medical Provider Network Doctors in the Bay Area, go to the Berkshire Hathaway MPN website: www.bhhc.com An employee can select any Doctor within the network.