Form 877 - Request For Medical/dental Records Or Information
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1REQUESTING ACTIVITY -
REQUEST FOR
DATE
Complete Items 1 through 10 (Except 8b); also
MEDICAL/DENTAL RECORDS
complete Item 19.
ADDRESSEE -
Complete Items 8b, 11 to 14 or 15 to 18, as appropriate,
OR INFORMATION
final referrer shall return to requester.
1. PATIENT (Last Name - First Name - Middle Name)
3.
STATUS
MILITARY
VA BENEFICIARY
DEPENDENT
FEDERAL EMPLOYEE
2. ORGANIZATION AND PLACE OF TREATMENT
OTHER (Specify)
3a. NAME OF SPONSOR (If dependent)
5.
IDENTIFYING INFORMATION
4. TO (Include ZIP Code)
a. SERVICE NUMBER
b. GRADE/RATE
c. SOCIAL SECURITY ACCOUNT NO.
d. VA CLAIM NUMBER
e. DATE OF BIRTH (If Federal employee)
6. DATES OF TREATMENT (Inclusive)
7. DISEASE OR INJURY
8.
a. RECORDS REQUESTED
b. RECORDS FORWARDED
9. REMARKS
MIL VA
MIL
VA
CLINICAL
OUTPATIENT
HEALTH RECORD
DENTAL RECORD
X-RAY
MEDICAL REPORT CARDS, EMERGENCY
MEDICAL TAGS, FIELD MEDICAL CARDS
ABSTRACT OF RATING SHEET
REPORT OF PHYSICAL EXAMINATION
ALL AVAILABLE RECORDS (Except
X-rays unless specifically requested)
10. SIGNATURE
OTHERS (List under remarks)
REPLY/REFERRAL
11. TO:
12. REMARKS
RECORDS CHECKED IN 8b FORWARDED.
NO RECORDS FOUND FOR PATIENT DURING ABOVE PERIOD.
MORE INFORMATION NEEDED. FURNISH FOLLOWING:
13. SIGNATURE
14. DATE
REPLY/SECOND REFERRAL
15. TO:
16. REMARKS
RECORDS CHECKED IN 8b FORWARDED.
NO RECORDS FOUND FOR PATIENT DURING ABOVE PERIOD.
MORE INFORMATION NEEDED. FURNISH FOLLOWING:
17. SIGNATURE
18. DATE
19. RETURN TO: (Include ZIP Code)
REQUESTING ACTIVITY WILL
ENTER COMPLETE ADDRESS
TO WHICH RECORDS OR FINAL
REPLY SHOULD BE MAILED.
DD FORM 877, SEP 67 (EG)
REPLACES EDITION OF 1 JAN. 60.
USAPPC V1.00
WHICH MAY BE USED.
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