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

soner refuses to sign. note that in the signature block. All refusals should be immediately repotted 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 - USMS Prisoner In formation I. Prisoner Nam (Lass First, SD) :t SM

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 loan 552 is to be retained in the prisoner's files. Section I - USMS Prisoner Information 1. Prisoner Name (Last. First MI) 2.

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)

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

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

If prisoner reuses to sign, note that in the signalize block. An who& should be immediately repotted to the Office of Interagency Medical Services. Prisoner Services Division. The completed LISM form 552 is to be retained in the prisoners files. Section I -1.1SMS Prisoner Information I. Prisoner Name Mast. NV. MI USMS P

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 1 - USMS Prisoner Information I. Prisoner Name (Last. Fint MB 12. I

soner refuses to sign. note that in the signature block. All (chisels 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 - IBMS Prison( IaforrinatIon I. Prisoner Name (Iasi. Fin'. P11) le

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

soner 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. Prisoner Name (Last. Fite. 5714/