MHANC CLP Declination of Curative Medical Attention

Date: _______________

I, _________________________, a resident of the CLP of MHANC, Inc. acknowledge

that I have been recommended and encouraged by CLP staff to seek appropriate medical
attention for my complaint(s) of __________________________________________________
in order to obtain treatment for it, and to otherwise help identify, and mitigate the advancement
of, any relevant disorder I may possess. I have been offered assistance by CLP staff to schedule
an appointment and to coordinate transportation to obtain appropriate consultation for my
aforementioned complaint. I was educated by CLP staff on what such a consultation typically
entails, on the likely benefits of obtaining such a consultation, and on the potential risks of not
obtaining such a consultation. On this date, I decline to obtain medical attention for my
aforementioned complaint. Furthermore, I acknowledge that if at any time in the future I decide
to obtain medical attention for my aforementioned complaint, CLP staff will assist me in
obtaining an appropriate appointment and coordinating transportation for it.

______________________________________
Printed Name of CLP Resident

______________________________________ Date Signed: __________________

Signature of CLP Resident

______________________________________
Printed Name of Witness (MHANC, Inc. CLP)

______________________________________ Date Signed: __________________

Signature of Witness

File Location: F:(MHACOMMON)\CLP Forms\Cushman-Haypath House\Declination of Curative Medical Attention