Blank USMS prisoner medical records release form (USM-552)

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
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65. IBM USM-516
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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
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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
149. IBM USM-500
150. IBM USM-501
151. IBM USM-502
152. IBM USM-503
153. IBM USM-504
154. IBM USM-505
155. IBM USM-506
156. IBM USM-507
157. IBM USM-508
158. IBM USM-509
159. IBM USM-510
160. IBM USM-511
161. IBM USM-512
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184. IBM USM-535
185. IBM USM-536
186. IBM USM-537
187. IBM USM-538
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189. IBM USM-540
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211. IBM USM-563
212. IBM USM-564
213. IBM USM-565
214. IBM USM-566
215. IBM USM-567
216. IBM USM-568
217. IBM USM-569
218. IBM USM-570
219. IBM USM-571
220. IBM USM-572
221. IBM USM-573
222. IBM USM-574
223. IBM USM-575
224. IBM USM-576
225. IBM USM-577
226. IBM USM-578
227. IBM USM-579
228. IBM USM-580
229. IBM USM-581
230. IBM USM-582
231. IBM USM-583
232. IBM USM-584
233. IBM USM-585
234. IBM USM-586
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237. IBM USM-589
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240. IBM USM-592
241. IBM USM-593
242. IBM USM-594
243. IBM USM-595
244. IBM USM-596
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248. IBM USM-500
249. IBM USM-501
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254. IBM USM-506
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256. IBM USM-508
257. IBM USM-509
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260. IBM USM-512
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262. IBM USM-514
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264. IBM USM-516
265. IBM USM-517
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270. IBM USM-522
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279. IBM USM-531
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281. IBM USM-533
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283. IBM USM-535
284. IBM USM-536
285. IBM USM-537
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288. IBM USM-540
289. IBM USM-541
290. IBM USM-542
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306. IBM USM-559
307. IBM USM-560
308. IBM USM-561
309. IBM USM-562
310. IBM USM-563
311. IBM USM-564
312. IBM USM-565
313. IBM USM-566
314. IBM USM-567
315. IBM USM-568
316. IBM USM-569
317. IBM USM-570
318. IBM USM-571
319. IBM USM-572
320. IBM USM-573
321. IBM USM-574
322. IBM USM-575
323. IBM USM-576
324. IBM USM-577
325. IBM USM-578
326. IBM USM-579
327. IBM USM-580
328. IBM USM-581
329. IBM USM-582
330. IBM USM-583
331. IBM USM-584
332. IBM USM-585
333. IBM USM-586
334. IBM USM-587
335. IBM USM-588
336. IBM USM-589
337. IBM USM-590
338. IBM USM-591
339. IBM USM-592
340. IBM USM-593
341. IBM USM-594
342. IBM USM-595
343. IBM USM-596
344. IBM USM-597
345. IBM USM-598
346. IBM USM-599
347. IBM USM-500
348. IBM USM-501
349. IBM USM-502
350. IBM USM-503
351. IBM USM-504
352. IBM USM-505
353. IBM USM-506
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355. IBM USM-508
356. IBM USM-509
357. IBM USM-510
358. IBM USM-511
359. IBM USM-512
360. IBM USM-513
361. IBM USM-514
362. IBM USM-515
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364. IBM USM-517
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385. IBM USM-538
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387. IBM USM-540
388. IBM USM-541
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411. IBM USM-565
412. IBM USM-566
413. IBM USM-567
414. IBM USM-568
415. IBM USM-569
416. IBM USM-570
417. IBM USM-571
418. IBM USM-572
419. IBM USM-573
420. IBM USM-574
421. IBM USM-575
422. IBM USM-576
423. IBM USM-577
424. IBM USM-578
425. IBM USM-579
426. IBM USM-580
427. IBM USM-581
428. IBM USM-582
429. IBM USM-583
430. IBM USM-584
431. IBM USM-585
432. IBM USM-586
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435. IBM USM-589
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438. IBM USM-592
439. IBM USM-593
440. IBM USM-594
441. IBM USM-595
442. IBM USM-596
443. IBM USM-597
444. IBM USM-598
445. IBM USM-599
446. IBM USM-500
447. IBM USM-501
448. IBM USM-502
449. IBM USM-503
450. IBM USM-504
451. IBM USM-505
452. IBM USM-506
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454. IBM USM-508
455. IBM USM-509
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458. IBM USM-512
459. IBM USM-513
460. IBM USM-514
461. IBM USM-515
462. IBM USM-516
463. IBM USM-517
464. IBM USM-518
465. IBM USM-519
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467. IBM USM-521
468. IBM USM-522
469. IBM USM-523
470. IBM USM-524
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476. IBM USM-530
477. IBM USM-531
478. IBM USM-532
479. IBM USM-533
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481. IBM USM-535
482. IBM USM-536
483. IBM USM-537
484. IBM USM-538
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488. IBM USM-542
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507. IBM USM-562
508. IBM USM-563
509. IBM USM-564
510. IBM USM-565
511. IBM USM-566
512. IBM USM-567
513. IBM USM-568
514. IBM USM-569
515. IBM USM-570
516. IBM USM-571
517. IBM USM-572
518. IBM USM-573
519. IBM USM-574
520. IBM USM-575
521. IBM USM-576
522. IBM USM-577
523. IBM USM-578
524. IBM USM-579
525. IBM USM-580
526. IBM USM-581
527. IBM USM-582
528. IBM USM-583
529. IBM USM-584
530. IBM USM-585
531. IBM USM-586
532. IBM USM-587
533. IBM USM-588
534. IBM USM-589
535. IBM USM-590
536. IBM USM-591
537. IBM USM-592
538. IBM USM-593
539. IBM USM-594
540. IBM USM-595
541. IBM USM-596
542. IBM USM-597
543. IBM USM-598
544. IBM USM-599
545. IBM USM-500
546. IBM USM-501
547. IBM USM-502
548. IBM USM-503
549. IBM USM-504
550. IBM USM-505
551. IBM USM-506
552. IBM USM-507
553. IBM USM-508
554. IBM USM-509
555. IBM USM-510
556. IBM USM-512
557. IBM USM-513
558. IBM USM-514
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560. IBM USM-516
561. IBM USM-517
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566. IBM USM-522
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611. IBM USM-567
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613. IBM USM-569
614. IBM USM-570
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620. IBM USM-576
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623. IBM USM-579
624. IBM USM-580
625. IBM USM-581
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627. IBM USM-583
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630. IBM USM-586
631. IBM USM-587
632. IBM USM-588
633. IBM USM-589
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635. IBM USM-591
636. IBM USM-592
637. IBM USM-593
638. IBM USM-594
639. IBM USM-595
640. IBM USM-596
641. IBM USM-597
642. IBM USM-598
643. IBM USM-599
644. IBM USM-500
645. IBM USM-501
646. IBM USM-502
647. IBM USM-503
648. IBM USM-504
649. IBM USM-505
650. IBM USM-506
651. IBM USM-507
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653. IBM USM-509
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655. IBM USM-512
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660. IBM USM-517
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684. IBM USM-541
685. IBM USM-542
686. IBM USM-543
687. IBM USM-544
688. IBM USM-545
689. IBM USM-546
690. IBM USM-547
691. IBM USM-548

USAO 002267¶

EFTA_00020177¶