Promoting Patient Responsibility - Thurston County Chamber

Informed Refusal letter excerpt:
“On (date) you advised me that you do not wish to
undergo this (test/treatment) because (use the reason
patient provided) . During this discussion I expressed
my concerns about your decision and explained to you
the potential consequences of this decision, outlining
what it may mean to your health. To summarize, your
decision to forgo this (test/treatment) could result in,
but is not limited to, the following possibilities: (name
the significant consequences of forgoing care, e.g.,
failure to diagnose a life-threatening illness such as
cancer) . Again, with full knowledge of the potential
consequences of your decision, you have elected to
forgo the (test/treatment) that I have recommended. “
Physicians Insurance A Mutual Company