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.

Best at defending claims.

An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to a carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC has consistently maintained lower base rates than multispecialty carriers in the U.S.