EFTA00169869

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 USM form 552 is to be retained in the prisoner's files.

Section I - USMS Prisoner Information





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.



Original--Prisoner File

Copy to District File

Copy Upon Transfer



1. IBM USM-552
2. IBM USM-553
3. IBM USM-554
4. IBM USM-555
5. IBM USM-556
6. IBM USM-557
7. IBM USM-558
8. IBM USM-559
9. IBM USM-560
10. IBM USM-561
11. IBM USM-562
12. IBM USM-563
13. IBM USM-564
14. IBM USM-565
15. IBM USM-566
16. IBM USM-567
17. IBM USM-568
18. IBM USM-569
19. IBM USM-570
20. IBM USM-571
21. IBM USM-572
22. IBM USM-573
23. IBM USM-574
24. IBM USM-575
25. IBM USM-576
26. IBM USM-577
27. IBM USM-578
28. IBM USM-579
29. IBM USM-580
30. IBM USM-581
31. IBM USM-582
32. IBM USM-583
33. IBM USM-584
34. IBM USM-585
35. IBM USM-586
36. IBM USM-587
37. IBM USM-588
38. IBM USM-589
39. IBM USM-590
40. IBM USM-591
41. IBM USM-592
42. IBM USM-593
43. IBM USM-594
44. IBM USM-595
45. IBM USM-596
46. IBM USM-597
47. IBM USM-598
48. IBM USM-599
49. IBM USM-500
50. IBM USM-501
51. IBM USM-502
52. IBM USM-503
53. IBM USM-504
54. IBM USM-505
55. IBM USM-506
56. IBM USM-507
57. IBM USM-508
58. IBM USM-509
59. IBM USM-510
60. IBM USM-511
61. IBM USM-512
62. IBM USM-513
63. IBM USM-514
64. IBM USM-515
65. IBM USM-516
66. IBM USM-517
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68. IBM USM-519
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75. IBM USM-526
76. IBM USM-527
77. IBM USM-528
78. IBM USM-529
79. IBM USM-530
80. IBM USM-531
81. IBM USM-532
82. IBM USM-533
83. IBM USM-534
84. IBM USM-535
85. IBM USM-536
86. IBM USM-537
87. IBM USM-538
88. IBM USM-539
89. IBM USM-540
90. IBM USM-541
91. IBM USM-542
92. IBM USM-543
93. IBM USM-544
94. IBM USM-545
95. IBM USM-546
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111. IBM USM-562
112. IBM USM-563
113. IBM USM-564
114. IBM USM-565
115. IBM USM-566
116. IBM USM-567
117. IBM USM-568
118. IBM USM-569
119. IBM USM-570
120. IBM USM-571
121. IBM USM-572
122. IBM USM-573
123. IBM USM-574
124. IBM USM-575
125. IBM USM-576
126. IBM USM-577
127. IBM USM-578
128. IBM USM-579
129. IBM USM-580
130. IBM USM-581
131. IBM USM-582
132. IBM USM-583
133. IBM USM-584
134. IBM USM-585
135. IBM USM-586
136. IBM USM-587
137. IBM USM-588
138. IBM USM-589
139. IBM USM-590
140. IBM USM-591
141. IBM USM-592
142. IBM USM-593
143. IBM USM-594
144. IBM USM-595
145. IBM USM-596
146. IBM USM-597
147. IBM USM-598
148. IBM USM-599
150. IBM USM-500
151. IBM USM-501
152. IBM USM-502
153. IBM USM-503
154. IBM USM-504
155. IBM USM-505
156. IBM USM-506
157. IBM USM-507
158. IBM USM-508
159. IBM USM-509
160. IBM USM-510
161. IBM USM-511
162. IBM USM-512
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164. IBM USM-514
165. IBM USM-515
166. IBM USM-516
167. IBM USM-517
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169. IBM USM-519
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172. IBM USM-522
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180. IBM USM-530
181. IBM USM-531
182. IBM USM-532
183. IBM USM-533
184. IBM USM-534
185. IBM USM-535
186. IBM USM-536
187. IBM USM-537
188. IBM USM-538
189. IBM USM-539
190. IBM USM-540
191. IBM USM-541
192. IBM USM-542
193. IBM USM-543
194. IBM USM-544
195. IBM USM-545
196. IBM USM-546
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208. IBM USM-558
209. IBM USM-560
210. IBM USM-561
211. IBM USM-562
212. IBM USM-563
213. IBM USM-564
214. IBM USM-565
215. IBM USM-566
216. IBM USM-567
217. IBM USM-568
218. IBM USM-569
219. IBM USM-570
220. IBM USM-571
221. IBM USM-572
222. IBM USM-573
223. IBM USM-574
224. IBM USM-575
225. IBM USM-576
226. IBM USM-577
227. IBM USM-578
228. IBM USM-579
229. IBM USM-580
230. IBM USM-581
231. IBM USM-582
232. IBM USM-583
233. IBM USM-584
234. IBM USM-585
235. IBM USM-586
236. IBM USM-587
237. IBM USM-588
238. IBM USM-589
239. IBM USM-590
240. IBM USM-591
241. IBM USM-592
242. IBM USM-593
243. IBM USM-594
244. IBM USM-595
245. IBM USM-596
246. IBM USM-597
247. IBM USM-598
248. IBM USM-599
250. IBM USM-500
251. IBM USM-501
252. IBM USM-502
253. IBM USM-503
254. IBM USM-504
255. IBM USM-505
256. IBM USM-506
257. IBM USM-507
258. IBM USM-508
259. IBM USM-509
260. IBM USM-510
261. IBM USM-511
262. IBM USM-512
263. IBM USM-513
264. IBM USM-514
265. IBM USM-515
266. IBM USM-516
267. IBM USM-517
268. IBM USM-518
269. IBM USM-519
270. IBM USM-520
271. IBM USM-521
272. IBM USM-522
273. IBM USM-523
274. IBM USM-524
275. IBM USM-525
276. IBM USM-526
277. IBM USM-527
278. IBM USM-528
279. IBM USM-529
280. IBM USM-530
281. IBM USM-531
282. IBM USM-532
283. IBM USM-533
284. IBM USM-534
285. IBM USM-535
286. IBM USM-536
287. IBM USM-537
288. IBM USM-538
289. IBM USM-539
290. IBM USM-540
291. IBM USM-541
292. IBM USM-542
293. IBM USM-543
294. IBM USM-544
295. IBM USM-545
296. IBM USM-546
297. IBM USM-547
298. IBM USM-548
299. IBM USM-550
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301. IBM USM-552
302. IBM USM-553
303. IBM USM-554
304. IBM USM-555
305. IBM USM-556
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307. IBM USM-558
308. IBM USM-559
309. IBM USM-560
310. IBM USM-561
311. IBM USM-562
312. IBM USM-563
313. IBM USM-564
314. IBM USM-565
315. IBM USM-566
316. IBM USM-567
317. IBM USM-568
318. IBM USM-569
319. IBM USM-570
320. IBM USM-571
321. IBM USM-572
322. IBM USM-573
323. IBM USM-574
324. IBM USM-575
325. IBM USM-576
326. IBM USM-577
327. IBM USM-578
328. IBM USM-579
329. IBM USM-580
330. IBM USM-581
331. IBM USM-582
332. IBM USM-583
333. IBM USM-584
334. IBM USM-585
335. IBM USM-586
336. IBM USM-587
337. IBM USM-588
338. IBM USM-589
339. IBM USM-590
340. IBM USM-591
341. IBM USM-592
342. IBM USM-593
343. IBM USM-594
344. IBM USM-595
345. IBM USM-596
346. IBM USM-597
347. IBM USM-598
348. IBM USM-599
350. IBM USM-500
351. IBM USM-501
352. IBM USM-502
353. IBM USM-503
354. IBM USM-504
355. IBM USM-505
356. IBM USM-506
357. IBM USM-507
358. IBM USM-508
359. IBM USM-509
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361. IBM USM-511
362. IBM USM-512
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364. IBM USM-514
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366. IBM USM-516
367. IBM USM-517
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381. IBM USM-531
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386. IBM USM-536
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389. IBM USM-539
390. IBM USM-540
391. IBM USM-541
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415. IBM USM-566
416. IBM USM-567
417. IBM USM-568
418. IBM USM-569
419. IBM USM-570
420. IBM USM-571
421. IBM USM-572
422. IBM USM-573
423. IBM USM-574
424. IBM USM-575
425. IBM USM-576
426. IBM USM-577
427. IBM USM-578
428. IBM USM-579
429. IBM USM-580
430. IBM USM-581
431. IBM USM-582
432. IBM USM-583
433. IBM USM-584
434. IBM USM-585
435. IBM USM-586
436. IBM USM-587
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443. IBM USM-594
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445. IBM USM-596
446. IBM USM-597
447. IBM USM-598
448. IBM USM-599
450. IBM USM-500
451. IBM USM-501
452. IBM USM-502
453. IBM USM-503
454. IBM USM-504
455. IBM USM-505
456. IBM USM-506
457. IBM USM-507
458. IBM USM-508
459. IBM USM-509
460. IBM USM-510
461. IBM USM-511
462. IBM USM-512
463. IBM USM-513
464. IBM USM-514
465. IBM USM-515
466. IBM USM-516
467. IBM USM-517
468. IBM USM-518
469. IBM USM-519
470. IBM USM-520
471. IBM USM-521
472. IBM USM-522
473. IBM USM-523
474. IBM USM-524
475. IBM USM-525
476. IBM USM-526
477. IBM USM-527
478. IBM USM-528
479. IBM USM-529
480. IBM USM-530
481. IBM USM-531
482. IBM USM-532
483. IBM USM-533
484. IBM USM-534
485. IBM USM-535
486. IBM USM-536
487. IBM USM-537
488. IBM USM-538
489. IBM USM-539
490. IBM USM-540
491. IBM USM-541
492. IBM USM-542
493. IBM USM-543
494. IBM USM-544
495. IBM USM-545
496. IBM USM-546
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508. IBM USM-559
509. IBM USM-560
510. IBM USM-561
511. IBM USM-562
512. IBM USM-563
513. IBM USM-564
514. IBM USM-565
515. IBM USM-566
516. IBM USM-567
517. IBM USM-568
518. IBM USM-569
519. IBM USM-570
520. IBM USM-571
521. IBM USM-572
522. IBM USM-573
523. IBM USM-574
524. IBM USM-575
525. IBM USM-576
526. IBM USM-577
527. IBM USM-578
528. IBM USM-579
529. IBM USM-580
530. IBM USM-581
531. IBM USM-582
532. IBM USM-583
533. IBM USM-584
534. IBM USM-585
535. IBM USM-586
536. IBM USM-587
537. IBM USM-588
538. IBM USM-589
539. IBM USM-590
540. IBM USM-591
541. IBM USM-592
542. IBM USM-593
543. IBM USM-594
544. IBM USM-595
545. IBM USM-596
546. IBM USM-597
547. IBM USM-598
548. IBM USM-599
550. IBM USM-500
551. IBM USM-501
552. IBM USM-502
553. IBM USM-503
554. IBM USM-504
555. IBM USM-505
556. IBM USM-506
557. IBM USM-507
558. IBM USM-508
559. IBM USM-509
560. IBM USM-510
561. IBM USM-512
562. IBM USM-513
563. IBM USM-514
564. IBM USM-515
565. IBM USM-516
566. IBM USM-517
567. IBM USM-518
568. IBM USM-519
569. IBM USM-520
570. IBM USM-521
571. IBM USM-522
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579. IBM USM-530
580. IBM USM-531
581. IBM USM-532
582. IBM USM-533
583. IBM USM-534
584. IBM USM-535
585. IBM USM-536
586. IBM USM-537
587. IBM USM-538
588. IBM USM-539
589. IBM USM-540
590. IBM USM-541
591. IBM USM-542
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595. IBM USM-546
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605. IBM USM-556
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607. IBM USM-558
608. IBM USM-559
609. IBM USM-560
610. IBM USM-561
611. IBM USM-562
612. IBM USM-563
613. IBM USM-564
614. IBM USM-565
615. IBM USM-566
616. IBM USM-567
617. IBM USM-568
618. IBM USM-569
619. IBM USM-570
620. IBM USM-571
621. IBM USM-572
622. IBM USM-573
623. IBM USM-574
624. IBM USM-575
625. IBM USM-576
626. IBM USM-577
627. IBM USM-578
628. IBM USM-579
629. IBM USM-580
630. IBM USM-581
631. IBM USM-582
632. IBM USM-583
633. IBM USM-584
634. IBM USM-585
635. IBM USM-586
636. IBM USM-587
637. IBM USM-588
638. IBM USM-589
639. IBM USM-590
640. IBM USM-591
641. IBM USM-592
642. IBM USM-593
643. IBM USM-594
644. IBM USM-595
645. IBM USM-596
646. IBM USM-597
647. IBM USM-598
648. IBM USM-599
650. IBM USM-500
651. IBM USM-501
652. IBM USM-502
653. IBM USM-503
654. IBM USM-504
655. IBM USM-505
656. IBM USM-506
657. IBM USM-507
658. IBM USM-508
659. IBM USM-509
660. IBM USM-510
661. IBM USM-512
662. IBM USM-513
663. IBM USM-514
664. IBM USM-515
665. IBM USM-516
666. IBM USM-517
667. IBM USM-518
668. IBM USM-519
669. IBM USM-520
670. IBM USM-521
671. IBM USM-522
672. IBM USM-523
673. IBM USM-524
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675. IBM USM-526
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677. IBM USM-528
678. IBM USM-529
679. IBM USM-530
680. IBM USM-531
681. IBM USM-532
682. IBM USM-533
683. IBM USM-534
684. IBM USM-535
685. IBM USM-536
686. IBM USM-537
687. IBM USM-538
688. IBM USM-539
689. IBM USM-540
690. IBM USM-541
691. IBM USM-542
692. IBM USM-543
693. IBM USM-544
694. IBM USM-545
695. IBM USM-546
696. IBM USM-547
697. IBM USM-548
698.



USAO 002267






EFTA_00020177