Marshals Service medical records release form for a prisoner, Nov. 2019

EFTA00140913¶

United States Marshals Service (USMS) PRISONER MEDICAL RECORDS RELEASE FORM¶

INSTRUCTIONS: Section I is to be completed by the USMS Intake Officer. Sections II & III are to be completed by the prisoner. Section II may be completed by the USMS Intake Officer if the prisoner is unable or unwilling, but Section III must be signed by the prisoner. If prisoner refuses to sign, note that in the signature block. All refusals should be immediately reported to the Office of Interagency Medical Services, Prisoner Services Division. The completed Form USM-552 is to be retained in the prisoner’s files.¶

Section I - USMS Prisoner Information¶

1. Prisoner Name (Last, First, MI) NOEL, TOYA

2. USMS Prisoner

3. District Name SDNY

4. District #

5. Custody Date (Mo/Day/Yr) 11/19/2019

Section II - Prisoner Personal Data And Medical Information¶

6. Date of Birth(Mg/Day/Yr)		7. Social Security No
8. Medical Insurance Information
A) Insurance Company Name	B) Policy Number		C) Medicare /Medicaid Coverage?☐Yes ☐No
9. Name of Your Physician		10. Phone Number( )

Section III - Medical Consent 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.¶

Signature of Prisoner	Date
Signature of USMS Intake Officer	Date

Original—Prisoner File¶

Copy to District File¶

Copy Upon Transfer¶

| Form | USM-552 |¶

| :--- | :--- |¶

| Est. | 6/98 |¶

SDNY_TN_00020917¶