Declination of Medical Treatment Form

______________________ 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:
An employee can select any Doctor within the network.