EFTA00059526

Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Sex: M
Provider: Lab Result Receive
Facility: NYM

Encounter Date: 07/10/2019 16:58

Cosigned by MD on 07/14/2019 18:12.

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| :--- | :--- |
| BP-S358.060 | |
| SEP 05 | |

MEDICAL TREATMENT REFUSAL

CDFRM

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:

EYE DOCTOR EVALUATION.

The following treatment(s) was/were recommended:

EYE DOCTOR EVALUATION.

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:

INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES.

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.