NA Form 13055: Request for Information Needed to Reconstruct Medical Data

Enter the NAME OF PATIENT USED AT TIME OF TREATMENT, SERVICE NO., SOCIAL SECURITY NO. and BRANCH OF SERVICE.

For each treatment, enter the NATURE OF ILLNESS, INJURY OR TREATMENT.

Enter the TREATMENT DATES FROM and TO (MO/YR). The National Personnel Records Center needs to know the exact month(s) as well as the year of treatment; the year alone is not enough. If you don't know the exact month, then please tell the National Personnel Records Center the season and year.

CHECK ONE: IN-PATIENT or OUT-PATIENT.

Enter the ORGANIZATION TO WHICH ASSIGNED. Furnish specific units to include company, battalion, regiment, squadron, group, wing, etc.

Enter the NAME AND LOCATION OF HOSPITAL, DISPENSARY OR MEDICAL FACILITY WHERE TREATED.

VETERAN SIGN HERE. To provide the information requested the National Personnel Records Center must have the signature of the person whose records are involved. If the person is deceased, the next of kin must sign and provide proof of death and evidence of kinship. For release purposes the next of kin is defined as any of the following: unremarried widow or widower; son or daughter; father or mother; brother or sister. If the person is legally incompetent, the court-appointed guardian must sign and furnish a copy of the court order adjudging incompetence and appointing the guardian.

RELEASE AUTHORIZATION: I hereby authorize release of the requested information/documents to the person indicated at right.

If signed by other than veteran show relationship to veteran.

Enter the DATE OF REQUEST.

Please type or print clearly the COMPLETE RETURN ADDRESS (to be mailed to): name, street number, city, state and zip code.

Enter the E-MAIL ADDRESS and the Daytime Phone No. with area code.

Send completed forms to the NATIONAL PERSONNEL RECORDS CENTER (Military Personnel Records), 1 Archives Drive, St. Louis, MO 63138-1002.

The medical record needed to answer your request is not in the files of the National Personnel Records Center. If the record were in the files on July 12, 1973, it would have been in the area that suffered the most damage in the fire on that date and may have been destroyed.

Some medical records were transferred to the Department of Veterans Affairs, formerly the Veterans Administration (VA), before the 1973 fire. The VA would have obtained the record to process a claim for benefits based on a service-connected injury or illness, and if so, the record should still be available from the VA. If you believe that such a claim was filed with the VA before July 1973, you should request the medical record by calling your nearest VA facility at 1-800-827-1000.

If the medical record was not transferred to the VA, there are also some alternate record sources available which often contain information concerning illness or injury while in the military service. One limited source of such information pertains to treatment received primarily at Army hospitals during some years from 1942 through 1954. If such information is available on the person named in this request, it is attached. If such information is not available, or it is attached and you find that it does not meet your needs, the National Personnel Records Center will attempt to use other alternate sources. Please note, however, that these other alternate sources usually show only dates of treatment or hospitalization and rarely show diagnosis or treatment given.