EFTA00040025


POD Forms - USM552_1

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POD Forms • Pages • USMN521

U.S. Department of Justice

United States Marshals Service (USMS)

Form Date : 7/8/2019

## PRISONER MEDICAL RECORDS RELEASE FORM

Document Number: 54-054-1921

INSTRUCTIONS:

Section I. II & III is to be completed by the USMS Intake Officers. Section III must be signed by the prisoner

Section 1- USMS Prisoner Information

<table border="1"><tr><td>1. Prisoner Name(Last, First, MI):</td><td>2. USMS Prisoner:</td><td>3. Date of Birth(Mo/Day/Yy):</td></tr><tr><td>EPSTEIN,JEFFREY EOWARD</td><td>76318-054</td><td>1/20/1953</td></tr><tr><td>4. District #:</td><td>5. District Name:</td><td>6. Office</td></tr><tr><td>54</td><td>Southern District of New York</td><td>500 PEARL ST.</td></tr></table>

Section R - Prisoner Personal And Medical Information

D) Phone Number:

8. Medicare/Medicaid Coverage? ⊙ Yes ○ No

Section III- Medical Consort And Records Release

I certify that the information I have provided above is true to the best of my knowledge.

I hereby authorize the United States Marshals Service to request, review, and have access to all medical records of care provided to me during the time that I am in the custody of that agency, and to all other medical records deemed necessary for the purposes of providing me with appropriate medical care, adjudicating medical bills for health care services provided to me while in the custody of the United States Marshals Service, and for infectious disease clearances

Refused To Sign: □

USMS Representative:

(b) (7)(E)