Risk Management

Refusal of Recommended Medical or Surgical Treatment


Patient Name:

Dr. ___________ informed me of the following:

I have the following condition(s):
The doctor recommends:
The recommended treatment consists of:
The purpose of the recommended treatment is:

I should get the recommended treatment within the following time period:
The possible alternative(s) to the recommended treatment:
The consequences of not getting the recommended treatment or the above described alternative(s):

I understand that my failure to accept the recommended treatment may endanger my vision, life, or health; I nonetheless refuse to consent to it.

My reason for refusal is:


Patient (or person authorized to sign for patient)                Date

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Six reasons OMIC is the best choice for ophthalmologists in America.

Consistent return of premium.

Publicly-traded insurance companies exist to make profits for shareholders while physician-owned carriers often return profits to their policyholders. Don’t underestimate this benefit; it can add up to tens of thousands of dollars over the course of your career. OMIC has one of the most generous dividend programs for ophthalmologists and has returned more than $90 Million to our members through dividends.