Epstein Secrets

III - Medical Consent And Records Release I easily nut the information I love providedabore is erne to the best of my knosidedgc I hereby authorize the United States Marshals Service to moven. review, and kw:caeca: to all medical records of cam provided to me during the time that t am tn the custody of that agency. and to all oil

soner refuses to sign, note that in the signature block. All refusals should be immediately repotted to the Office of Interagency Medina! Services. Prisoner Services Division. The completed USM form 552 is to be retained in the prisoner's files Section I - USMS Prisoner Information I. Prison: Name (Last. First. Mil I?I)

- 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 al

soner 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 I. Prisoner Name (Last, First, MI) Ne

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 Distri

soner 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 I. Prisoner Name (Last, First, MI) 11

Ill - Medical Consent And Records Release I certify that the information I have providedabove is true to the best of my kaowledgc. hereby authorize the United States Marshals Service to request review, and have access to all medical records of cam provided to mc during the lime dial I am St the custody of that agency. and to all

soner 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. Prisoner Name Mast. First. Ml) USM