EFTA00132695

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

MEDICAL TREATMENT REFUSAL

CDFRM

U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

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.

<table border="1"><tr><td></td><td>X-RAY</td><td>7-10-2019</td></tr><tr><td>Counseled by</td><td>.</td><td>Date</td></tr></table>



Signature of Witness 7-10-19 Date