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DD Form 877-1, Request for Medical/Dental …

3. YEAR OF TREATMENT (IP records - only one year per Request . All others - only last year of treatment) 9700 PAGE AVE., ST. LOUIS, MO 63132-5100 Request FOR Medical/Dental RECORDS FROM THE NATIONAL PERSONNEL RECORDS CENTER (NPRC) (ST. LOUIS, MISSOURI)(For Agency Use Only)See Instructions on back before completing form . REQUESTING ACTIVITY: Complete Items 1 through 11 and Item 14. ADDRESSEE: Complete Items 12 and Request DATE (YYYYMMDD)2. PATIENT'S NAME (At time of treatment) (Last, First, Middle)4. NAME OF FACILITY WHERE PATIENT WAS TREATED5. DISEASE OR INJURY 9. RECORDS LOCATOR INFORMATION (If the requesting facility (Item 14) is the same as the records creating facility (Item 4), complete Items through to expedite a response to this Request .)

dd form 877-1 (back), apr 1998 instructions for requesting medical treatment records from the national personnel records center (nprc), st. louis, mo

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Transcription of DD Form 877-1, Request for Medical/Dental …

1 3. YEAR OF TREATMENT (IP records - only one year per Request . All others - only last year of treatment) 9700 PAGE AVE., ST. LOUIS, MO 63132-5100 Request FOR Medical/Dental RECORDS FROM THE NATIONAL PERSONNEL RECORDS CENTER (NPRC) (ST. LOUIS, MISSOURI)(For Agency Use Only)See Instructions on back before completing form . REQUESTING ACTIVITY: Complete Items 1 through 11 and Item 14. ADDRESSEE: Complete Items 12 and Request DATE (YYYYMMDD)2. PATIENT'S NAME (At time of treatment) (Last, First, Middle)4. NAME OF FACILITY WHERE PATIENT WAS TREATED5. DISEASE OR INJURY 9. RECORDS LOCATOR INFORMATION (If the requesting facility (Item 14) is the same as the records creating facility (Item 4), complete Items through to expedite a response to this Request .)

2 Contact your Records Management Office for this information.) a. ACCESSION NUMBERb. AGENCY BOX NUMBERc. NPRC LOCATION NUMBERd. REGISTRY NUMBER (If applicable)10. REMARKS11. SIGNATURE OF REQUESTER12. REPLY/REFERRALa. FIRST RESPONSEb. SECOND RESPONSE(1) REQUESTED RECORDS FORWARDED(2) NO RECORD FOUND FOR PATIENT DURING ABOVE PERIOD(3) RECORD NOT YET RETIRED TO NPRC(4) MORE INFORMATION NEEDED (See Remarks below)(5) Request REFERRED TO: (See Remarks below)(6) RETURN MILITARY (Service Member's) HEALTH RECORDS TO: NPRC, ATTN: 13. REMARKS(7) SIGNATURE(8) DATE SIGNED (YYYYMMDD)(7) SIGNATURE(8) DATE SIGNED (YYYYMMDD)14. RETURN TO (Include ZIP Code)NOTE: Enter complete address towhich the records or final replyshould be mailed.

3 Enter legibly onboth the original and form 877-1, APR 1998 Adobe Professional STATUS AT TIME OF TREATMENT (X one)a. MILITARYb. RETIRED MILITARYc. DEPENDENTd. FEDERAL EMPLOYEEe. OTHER7. IDENTIFIERS (Provide information as appropriate on line a., b., c., or , according to status selected.)(1) SSN(2) SN (If applicable)(1) SSN(1) SPONSOR'S SSN(1) SSN(2) SN (If applicable)(2) SPONSOR'S NAME (Last, First, Middle Initial)(2) DATE OF BIRTH (YYYYMMDD)(3) BRANCH OF SERVICE (At time of treatment) (3) BRANCH OF SERVICE (At time of treatment) (3) OTHER DEPENDENT INFORMATION(3) OTHER FEDERAL EMPLOYEE INFORMATION(4) DATES OF SERVICE (Including reserve duty)(4) DATE RETIRED (YYYYMMDD)8.

4 TYPE OF TREATMENT (X one per Request )INPATIENTHEALTH RECORDDENTALPSY/CONSULTATIONINPATIENTOUT PATIENTDENTALPSY/CONSULTATIONINPATIENTOU TPATIENTDENTALPSY/CONSULTATIONINPATIENTO UTPATIENTDENTALPSY/CONSULTATIONDD form 877-1 (BACK), APR 1998 INSTRUCTIONS FOR REQUESTING medical TREATMENT RECORDS FROM THE NATIONAL PERSONNELRECORDS CENTER (NPRC), ST. LOUIS, MODD form 877-1 is the only Request form whichNPRC will accept from military facilities for retiredmedical treatment records. Read the informationbelow before completing the front of this Please check to make sure that records fromrecent years have been retired to NPRC beforepreparing this form . Most inactive records areheld at the military treatment facility 1 to 5 yearsafter the end of the treatment year beforeretirement.

5 See paragraph 6 below for additionalinformation. For recent records, contact theRecords Management Officer of the related facilityto find out if records have been retired, if they arein a records holding area, or are still at the Prepare the Request form in TO EXPEDITE THE RECEIPT OF RECORDS,YOU MUST COMPLETE ITEMS 1 THROUGH 11 AND ITEM 14. Incomplete forms will be This form is authorized for use by militarymedical treatment facilities ONLY. Do notdistribute to individuals for personal All entries relate to a patient AT TIME Submit one form per patient, per type and yearof records RECORDS - Inpatient (clinical) recordsgenerally contain documentation of treatmentduring a single calendar year.

6 These records arenormally retired and identified by the hospitalwhich created them. Requests for inpatientrecords must include the facility name and year RECORDS - NPRC maintains healthrecords for all Coast Guard and for militarypersonnel separated from service prior to thefollowing dates: Army - October 16, 1992; AirForce - May 1, 1994; Navy - January 31, 1994;and Marine Corps - May 1, 1994. After thesedates, the health records are maintained by: DEPARTMENT OF VETERANS AFFAIRS RECORDS MANAGEMENT CENTER BOX 5020 ST. LOUIS, MO 63115 OTHER medical RECORDS - Outpatient, dental ,psychiatric, and consultation records are generallycumulative. A record may contain documentscovering several years from several facilities.

7 Whenthese records reach inactive status, they aregenerally retired and identified by the facility atwhich the patient was last treated or for outpatient, dental , psychiatric, orconsultation records, therefore, must include thetype of record being requested, the facility and lastyear of treatment. Please be aware that reassignments after lasttreatment may result in records (outpatient, dental ,psychiatric, and consultation) being transferred toand retired from other military treatment facilities. Ifno treatment was received at the medical facility atthe place of final assignment, please write the nameand location of that facility and the year departed inItem 10, "Remarks."7. Send the original and first copy of the completedform to the NPRC location indicated below whichmaintains the records you are requesting.

8 Retain thethird copy for your files. For military (active duty and retired) treated atArmy, Air Force, and Navy medical treatmentfacilities; and dependent and other non-militarypersonnel treated at Navy medical treatmentfacilities: NATIONAL PERSONNEL RECORDS CENTER ATTN: ORGANIZATIONAL RECORDS 9700 PAGE AVENUE ST. LOUIS, MO 63132-5100 For dependent and other non-military personneltreated at Army and Air Force medical treatmentfacilities: NATIONAL PERSONNEL RECORDS CENTER ATTN: REFERENCE SERVICE BRANCH 111 WINNEBAGO STREET ST. LOUIS, MO 631188. Please enter the return address completely andlegibly on the original and copy of the Request .