EFTA00059520¶
| BP-S358.060 | |
| SEP 05 |
MEDICAL TREATMENT REFUSAL¶
CDFRM¶
FEDERAL BUREAU OF PRISONS¶
U.S. DEPARTMENT OF JUSTICE¶
| 7-10-2019 |
| Date |
I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s):¶
DESCRIBE CONDITION IN LAYMAN’S TERMINOLOGY:¶
66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR.¶
The following treatment(s) was/were recommended:¶
CHEST X-RAY¶
Federal Bureau of Prisons Medical staff members have carefully explained to me that the following possible consequences and/or complications may result because of my refusal to accept treatment:¶
WORSENING THE CONDITION IF THERE IS ANY FINDINGS¶
I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions.¶
NYM–NEWYORK MCC¶