OMB 3095-0039 Expires 7/31/2014
REQUEST FOR INFORMATION NEEDED TO RECONSTRUCT
MEDICAL DATA
The medical record needed to answer your request is not in our files. If the record were here 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, we 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.
To enable us to search secondary sources, please provide the information requested below. We need 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 us the season and year.
NAME OF PATIENT USED AT TIME OF TREATMENT |
SERVICE NO. |
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NATURE OF ILLNESS, INJURY OR TREATMENT
TREATMENT DATES
FROMTO
(MO/YR) (MO/YR)
CHECK ONE
IN-PATIENT OUT-PATIENT
ORGANIZATION TO
WHICH ASSIGNED (Furnish specific units to include company, battalion, regiment,
squadron, group, wing, etc.)
NAME AND LOCATION OF HOSPITAL, DISPENSARY OR MEDICAL FACILITY WHERE TREATED
To provide the information requested we 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.
VETERAN SIGN HERE:
(If signed by other than veteran show relationship to veteran)
DATE OF REQUEST:
Please type or print clearly COMPLETE RETURN ADDRESS (to be mailed to)
(name)
(street number)
(city) |
(state) |
(zip code) |
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E-MAIL ADDRESS |
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Daytime Phone No. with area code ( |
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Date
Prepared by
AFN-M
NATIONAL PERSONNEL RECORDS CENTER
(Military Personnel Records)
1 Archives Drive
St. Louis, MO 63138-1002
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION |
NA FORM 13055 (Page 1 of 2) (REV. 04/11) |
OMB 3095-0039 Expires 7/31/2014
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
The following information is provided in accordance with 5 U.S.C. 552a(e)(3) and applies to this form. Authority for collection of the information is 44 USC 2907, 3101, 3103 and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. If the requested information is not provided, it may delay servicing your inquiry because the National Personnel Records Center may not have all of the information needed to locate the record(s) sought. The purpose of the information on this form is to assist the National Personnel Records Center in locating the correct military service record(s) or information to
answer your inquiry. This form is then filed in the requested military service record as a record of disclosure. The form may be further disclosed with the military record to (1) a “Routine Use” as defined in the Privacy Act of 1974, 5 U.S.C. 552a (a)(7), and as
published by the Department of Defense, the military service departments, and the Department of Homeland Security (DHS, U.S. Coast Guard) in the Federal Register; (2) other individuals or offices who present written authorization of the veteran, the veteran’s next of kin when the veteran is deceased, the veteran’s legal representative officially designated in writing, or a legal guardian when
the veteran has been declared incompetent; or (3) pursuant to the order of a court of competent jurisdiction.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. The information requested on this form is being collected and used by the National Personnel Records Center to identify and locate military service records that could not be identified and located in response to the original inquiry. 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 ON PAGE 1.
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION |
NA FORM 13055 (Page 2 of 2) (REV. 04/11) |
