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I. corrections K Assault on LI: corrections K Leadership mk O Ci /Describe below, El Current or runner intelligence K SAM subjr:ct or candidate K Separation weds ilktecrine Mott I K Other !Describe helm.; Title/Code TES Page I or 3 Form USM-312 Rev 11/17 EFTA00040006 LAW liNFORCEMIA Remarks: Da
soner refuses to sign, note that in the signature block. All refusals should be immediately reported to the Otftce 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. nisoner Name (Last. First. MO 2 US
LE/corrections K Assault on LE/corrections K Leadership role K CI (Describe below) K Current or former intelligence K SAM subject or candidate K Separation needs (Describe below) K Other (Describe below) ASSOCIATES / CO-DEFENDANTS / RELATIVES CHILDREN SIGNIFICANT OTHER Relationship First, MI Scar/Ma
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
E/corrections Assault on LE/corrections Leadership role CI (Describe below) Remark K Current or former intelligence K SAM subject or candidate K Separation needs (Describe below) K Other (Describe below) Date of Birth ASSOCIATES / CO-DEFENDANTS / RELATIVES / CHILDREN SIGNIFICANT OTHER Relationship Co
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
Entities connected to both K Separation and Prisoner Services Division

Department of Justice
ORGANIZATIONthe Office of Interagency Medical Services
ORGANIZATIONK Correctional
ORGANIZATIONDistrict File
ORGANIZATIONMedical Insurance Information
ORGANIZATIONBooking Package
ORGANIZATIONthe United States Marshals Service
ORGANIZATIONK SAM
ORGANIZATIONLeon Black
PERSONUSMS Intake Officer
ORGANIZATIONNew York State Division of Criminal Justice Services
ORGANIZATION
Michael C.Green
PERSONPrisoner Medical Records Release Form)-
ORGANIZATION
NEW YORK NY
LOCATIONAlbany
LOCATION
Julie K. Brown
PERSONFederal Bureau of Investigation - New York
ORGANIZATIONLocation/Facility of Arrest
ORGANIZATIONBROADWAY FBI NY
ORGANIZATIONLong Term Medical Conditions
ORGANIZATION