EFTA00132685¶
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.¶
Patient’s Signature Date¶
Signature of Witness 7-10-19 Date¶
NYM-NEWYORK MCC¶