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Page 2670 eee MEDICAL TREATMENT REFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date |, 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 | understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. | hereby assume all responsibility for my physical and/or mental! condition, and release the Bureau of Prisons and its employees from aki and all liability for respecting and following my expressed wishes and directions. Date Patienys S “2 Date Kb MG); (DMT HC) 7-10-2019 i alae re : NYM—NEW YORK MCC Signature of Witness Date ; DOJ-OGR- 00026326