EFTA00110371

# Bureau of Prisons
Health Services
Clinical Encounter - Administrative Note

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Note Date: | 07/24/2019 15:10 |

| Sex: M Race:WHITE |
| :--- |
| Provider: MD |

| Reg #: | 76318-054 |
| :--- | :--- |
| Facility: NYM |
| Unit: H01 |

Admin Note - General Administrative Note encounter performed at Health Services.

Administrative Notes:

ADMINISTRATIVE NOTE 1 Provider: MD

PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED.

Copay Required: No

Cosign Required: No

Telephone/Verbal Order: No

Completed by MD on 07/24/2019 15:17

Generated 07/24/2019 15:17 by

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MD

Bureau of Prisons - NYM