Na Form 13042 - Request For Information Needed To Locate Medical Records printable pdf download

OMB No. 3095-0039

Expires 7/31/2014

REQUEST FOR INFORMATION NEEDED TO LOCATE MEDICAL RECORDS

WHEN

TO USE THIS FORM

Use this form to request the following categories of medical records from the National

Personnel Records Center:

Clinical (inpatient) records for a military service member, a military retiree, or a dependent of an active/retired military

member for hospitalization in a military medical treatment facility.

Outpatient records for a military retiree, a dependent of an active/retired military member, a civilian Federal employee, or

a dependent of a civilian employee for outpatient treatment in a military medical treatment facility.

WHEN

NOT TO USE THIS FORM:

Do not use this form to request the following:

Outpatient (health) records and dental records created for a person while in the military service. Request these records

by using Standard Form (SF) 180, Request Pertaining to Military Records or online via eVetRecs at

The SF 180 is available from most VA offices and other organizations that serve veterans and from the web at

VA hospital records. Please phone the VA at 1-800-827-1000 for help in obtaining these records. You will need to

provide your VA Claim Number.

HOW

TO USE THIS FORM

Use a separate form for each individual for whom you are requesting records.

Fill in page 2 of this form to the best of your ability.

Please be sure to read the section near the bottom entitled “Authorization To Receive Information From Medical

Records” and obtain the required authorization signature.

WHERE

TO SEND THIS FORM:

National Personnel Records Center

Military Personnel Records

1 Archives Drive

St. Louis, MO 63138-1002

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

Public burden reporting for this collection of information is estimated to be five minutes per response, including time for reviewing instructions and completing and

reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions

for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND

COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE ADDRESS SHOWN AT THE BOTTOM OF THIS PAGE

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

The following information is provided in accordance with U.S.C. 552a (e)(3) and applies to this form. Authority for collection of the information is 44 U.S.C. 2907,

3101, 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. The purpose of the

information on this form is to assist the National Personnel Records Center in locating the correct medical record(s) or information to answer your inquiry. If the

requested information is not provided, it may delay servicing your inquiry because the National Personnel Records Center may not have all the information

needed to locate the requested record(s). This form is then filed in the requested file as a record of disclosure. The form may also be disclosed to Department of

Defense components, Department of Homeland Security (DHS, U.S. Coast Guard) or a civilian agency if the National Personnel Records Center transfers all or

part of the medical record to one of these agencies.

Date

Prepared by

AFN

NATIONAL PERSONNEL RECORDS CENTER

Military Personnel Records

1 Archives Drive

St. Louis, MO 63138-1002

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

NA FORM 13042 (Page 1 of 2) (REV. 5/11)