Dd Form 877 1 PDF Details

The DD Form 877-1 is a critical document utilized by military facilities to request retired medical and dental records from the National Personnel Records Center (NPRC) located in St. Louis, Missouri. This form serves as the solitary medium through which the NPRC accepts requests for medical treatment records from military entities. Its utilization is mandated for acquiring records for military personnel, both active duty and retired, along with their dependents and certain federal employees. It meticulously outlines the need for complete information regarding the patient at the time of treatment, the specific type of records requested (whether inpatient, outpatient, dental, psychiatric, or consultation), and clear instructions for filling out and submitting the form. By requiring detailed information such as the patient's name, treatment year, and the facility where the treatment was administered, the form ensures that requests are accurately processed and records are correctly identified. Moreover, it emphasizes the importance of checking the retirement status of records and adhering to the submission directives to expedite the process. The detailed guidance provided aims at facilitating a smooth request process for military medical treatment facilities, ensuring they have the necessary information to support healthcare or benefits claims, historical research, or personal records retrieval.

QuestionAnswer
Form NameDd Form 877 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 877, dd 877, how do i fill out dd form877, dd 877 1

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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 13.

1.REQUEST DATE (YYYYMMDD) 2. PATIENT'S NAME (At time of treatment) (Last, First, Middle)

3. YEAR OF TREATMENT

 

 

4. NAME OF FACILITY WHERE PATIENT WAS TREATED

 

 

(IP records - only one year per request.

 

 

 

 

All

others -

only last

year of

treatment)

 

 

 

 

 

5. DISEASE OR INJURY

 

 

 

 

 

 

 

 

 

 

 

 

6. STATUS AT TIME OF

7. IDENTIFIERS (Provide information as appropriate on line a., b., c., or d./e.,

8. TYPE OF TREATMENT

TREATMENT (X one)

 

according to status selected.)

 

(X one per request)

 

 

 

 

 

 

 

 

 

 

 

a. MILITARY

(1)

SSN

 

(2) SN (If applicable)

 

INPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH RECORD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

BRANCH OF SERVICE (At time of

(4) DATES OF SERVICE (Including reserve duty)

 

DENTAL

 

 

 

 

 

treatment)

 

 

 

 

 

 

 

 

 

 

 

 

PSY/CONSULTATION

 

 

 

 

 

 

 

 

 

 

 

b. RETIRED MILITARY

(1) SSN

 

(2) SN (If applicable)

 

INPATIENT

 

 

 

 

 

 

 

OUTPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

BRANCH OF SERVICE (At time of

(4) DATE RETIRED (YYYYMMDD)

 

DENTAL

 

 

 

 

 

treatment)

 

 

 

 

 

 

 

 

 

 

 

 

PSY/CONSULTATION

 

 

 

 

 

 

 

 

 

 

 

c. DEPENDENT

(1)

SPONSOR'S SSN

(2) SPONSOR'S NAME (Last, First, Middle Initial)

 

INPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OUTPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

OTHER DEPENDENT INFORMATION

 

 

DENTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PSY/CONSULTATION

 

d. FEDERAL EMPLOYEE

(1)

SSN

 

(2) DATE OF BIRTH (YYYYMMDD)

 

INPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OUTPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. OTHER

(3)

OTHER FEDERAL EMPLOYEE INFORMATION

 

DENTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PSY/CONSULTATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.RECORDS LOCATOR INFORMATION (If the requesting facility (Item 14) is the same as the records creating facility (Item 4), complete Items 9.a. through 9.d. to expedite a response to this request. Contact your Records Management Office for this information.)

a. ACCESSION NUMBER

b. AGENCY BOX NUMBER

c. NPRC LOCATION NUMBER

 

d. REGISTRY NUMBER (If applicable)

 

 

 

 

 

10. REMARKS

 

 

11.

SIGNATURE OF REQUESTER

12. REPLY/REFERRAL

a. FIRST RESPONSE

b. 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:

9700 PAGE AVE., ST. LOUIS, MO

63132-5100

 

 

 

 

 

 

13. REMARKS

 

(7) SIGNATURE

(7) SIGNATURE

(8) DATE SIGNED (YYYYMMDD)

(8) DATE SIGNED (YYYYMMDD)

14.RETURN TO (Include ZIP Code)

NOTE: Enter complete address to which the records or final reply should be mailed. Enter legibly on both the original and copy.

DD FORM 877-1, APR 1998

Adobe Professional 8.0

INSTRUCTIONS FOR REQUESTING MEDICAL TREATMENT RECORDS FROM THE NATIONAL PERSONNEL

RECORDS CENTER (NPRC), ST. LOUIS, MO

DDForm 877-1 is the only request form which NPRC will accept from military facilities for retired medical treatment records. Read the information below before completing the front of this form.

1.Please check to make sure that records from recent years have been retired to NPRC before preparing this form. Most inactive records are held at the military treatment facility 1 to 5 years after the end of the treatment year before retirement. See paragraph 6 below for additional information. For recent records, contact the Records Management Officer of the related facility to find out if records have been retired, if they are in a records holding area, or are still at the facility.

2.Prepare the request form in triplicate.

3.TO EXPEDITE THE RECEIPT OF RECORDS, YOU MUST COMPLETE ITEMS 1 THROUGH 11 AND ITEM 14. Incomplete forms will be returned.

4.This form is authorized for use by military medical treatment facilities ONLY. Do not distribute to individuals for personal use.

5.All entries relate to a patient AT TIME OF TREATMENT.

6.Submit one form per patient, per type and year of records requested.

INPATIENT RECORDS - Inpatient (clinical) records generally contain documentation of treatment during a single calendar year. These records are normally retired and identified by the hospital which created them. Requests for inpatient records must include the facility name and year of treatment.

HEALTH RECORDS - NPRC maintains health records for all U.S. Coast Guard and for military personnel separated from service prior to the following dates: Army - October 16, 1992; Air Force - May 1, 1994; Navy - January 31, 1994; and Marine Corps - May 1, 1994. After these dates, the health records are maintained by:

DEPARTMENT OF VETERANS AFFAIRS RECORDS MANAGEMENT CENTER P.O. BOX 5020

ST. LOUIS, MO 63115

OTHER MEDICAL RECORDS - Outpatient, dental, psychiatric, and consultation records are generally cumulative. A record may contain documents covering several years from several facilities. When these records reach inactive status, they are generally retired and identified by the facility at which the patient was last treated or stationed. Requests for outpatient, dental, psychiatric, or consultation records, therefore, must include the type of record being requested, the facility and last year of treatment.

Please be aware that reassignments after last treatment may result in records (outpatient, dental, psychiatric, and consultation) being transferred to and retired from other military treatment facilities. If no treatment was received at the medical facility at the place of final assignment, please write the name and location of that facility and the year departed in Item 10, "Remarks."

7.Send the original and first copy of the completed form to the NPRC location indicated below which maintains the records you are requesting. Retain the third copy for your files.

For military (active duty and retired) treated at Army, Air Force, and Navy medical treatment facilities; and dependent and other non-military personnel treated at Navy medical treatment facilities:

NATIONAL PERSONNEL RECORDS CENTER ATTN: ORGANIZATIONAL RECORDS 9700 PAGE AVENUE

ST. LOUIS, MO 63132-5100

For dependent and other non-military personnel treated at Army and Air Force medical treatment facilities:

NATIONAL PERSONNEL RECORDS CENTER ATTN: REFERENCE SERVICE BRANCH 111 WINNEBAGO STREET

ST. LOUIS, MO 63118

8.Please enter the return address completely and legibly on the original and copy of the request.

DD FORM 877-1 (BACK), APR 1998

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2. Once your current task is complete, take the next step – fill out all of these fields - REMARKS, SIGNATURE OF REQUESTER, REPLYREFERRAL REQUESTED RECORDS, PAGE AVE ST LOUIS MO REMARKS, RETURN TO Include ZIP Code, a FIRST RESPONSE, b SECOND RESPONSE, SIGNATURE, SIGNATURE, DATE SIGNED YYYYMMDD, DATE SIGNED YYYYMMDD, and NOTE Enter complete address to with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Ways to prepare dd 877 navy portion 2

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