Epstein Secrets

on 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 loan 552 is to be retained in the prisoner's files. Section I - USMS Prisoner Information 1. Prison

// %Je Frrel, f 3. Daniel Name / 4, District fl ≤DK Section II - Prisoner Personal Data Mid Medical Information 6. Date Of Binh We/Day/Yr) 8. Medical Insurance Information A) litstwonce any Name vitfee ne4-1/4 64 Section III - Medical Consent And Records Release I certify that the information I have pivvidcd above

on 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 I. Prison

ct 2. USMS Prisoner 5. Custody Date (Mo/Day/Yr) Ohl la) Section 11 - Prisoner Personal Data And Medical Information 6. Date of Birth M Da /Y 8. Medical Insurance Information A) Insurance Company Name I3) Policy Number C) Medicare /Medicaid Coverage? K Yes K No 9. Name of Your Physician 10. Phone Number ( ) 'Nee

on 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 I. Prison

stodyDate (Mo/Day/Yr) 1111.0q Seel inn II - Prisoner Personal Data And Medical In formation 6. Date of Birt (M Day/Yr) 7. Social Security No. 8. Medical Insurance Information A) Insurance Company Name B) Policy Number C) Medicare /Medicaid Coverage? El Yes 9. Name of Your Physician 10. Phone Nu nber ( ) Section II

ion HI must be signed by the prisoner. If prisoner refuses to sign, note that in the signature block. Al! refusals should he 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. Prison

3. Oi3triet Name r f I4 District [2.USMS Prisoner Section It - Prisoner Personal Data And Medics! Information 6. Dale Of Birth IMo/DayrYr) 8. Medical Insurance Information A) Instira9ce comciany Name i U/Ofeid- , he -ALL ot si„ ry So. H .— 2211? 13g ) Policy tinstler /Mr( L') Medic c /Medicaid ve 3 ( C-11.4SS