90A-NY-3151227 Serial 98

FD-1036 (Rev. 10-16-2009)

# UNCLASSIFIED

FEDERAL BUREAU OF INVESTIGATION

Import Form

Form Type: OTHER - Other

Date: 09/06/2019

Title: (U) Medical Notes Regarding Jeffrey Epstein

Approved By: SSA

Drafted By:

Case ID #: 90A-NY-3151227

(U) UNSUB(S);

JEFFREY EPSTEIN - VICTIM;

DEATH INVESTIGATION

Synopsis: (U) On August 10, 2019, BOP SIS provided BOP medical notes regarding Jeffrey Epstein.



UNCLASSIFIED

EFTA00132684

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

CDFRM

MEDICAL TREATMENT REFUSAL

7-24-2019

U.S. DEPARTMENT OF HEALTH SERVICES

I, JEFFREY EPSTEIN 763, 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.

Counseled by Date

NYM—NEW YORK MCC