The NA 13036 form serves a crucial role in the authorization process for the release of military medical patient records. Crafted by the National Personnel Records Center, part of the National Archives and Records Administration, this document outlines a structured approach for individuals seeking to grant access to their confidential medical history specifically related to drug and alcohol rehabilitation. It essentially functions as a bridge, enabling the secure and consented exchange of sensitive information between military personnel and authorized recipients. The form is meticulously sectioned to capture essential details such as the social security or service number of the individual, the authorized recipient's details, the specifics of the treatment, and the purpose of the record release. Moreover, it emphasizes the importance of the individual's consent through required signatures, thereby upholding a high standard of privacy and confidentiality. The acknowledgement of the Paperwork Reduction Act and compliance with the Privacy Act of 1974 further underpins the form's adherence to legal requirements, ensuring that the collection, use, and disclosure of personal information are conducted with the utmost care and respect for individual rights. The NA 13036 form, with its expiration clause, also highlights the temporality and revocability of the authorization, providing individuals with control over their own records. This precise and regulated process ensures that the delicate handling of military medical records is conducted within a framework of transparency, consent, and legal compliance.
| Question | Answer |
|---|---|
| Form Name | Na Form 13036 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | national archivea form 13075, na form 13075 pdf, na form 13036, na form 13075 |
OMB No.
AUTHORIZATION FOR RELEASE OF MILITARY MEDICAL PATIENT RECORDS
NOTE: Records Center personnel complete blocks #1,2,3 and 6.
1. Social Security No. or Service No.
This Center has received a request from the facility shown below regarding your participation in the Drug/Alcohol Rehabilitation Program. In order for us to release this information we must have additional authorization from you. If you wish this information to be released to that facility, please complete blocks # 4, 5, and 7 to the best of your ability. Date and sign this form in blocks #8 and 9 and return to this Center at the address checked below as soon as possible.
2.Name of person authorized to receive records
3.Name and address of facility to receive records
4.Place where treatment occurred
5.Approximate beginning and ending dates of treatment
6.Specific type of treatment involved
7.Purpose for which records are needed
The National Personnel Records Center, National Archives and Records Administration, is hereby authorized to release copies of my military medical treatment records as described above.
THIS AUTHORIZATION EXPIRES WITHOUT EXPRESS REVOCATION 12 MONTHS FROM THE FOLLOWING DATE.
8.Date
9.Signature of individual whose records are requested
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 obtain specific permission to release certain information in response to the original request. 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
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 U.S.C. 2907, 3101, and 3103, and Public Law
Date
Prepared by
NATIONAL PERSONNEL RECORDS CENTER
(Military Personnel Records)
1 Archives Drive
St. Louis, MO
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION |
NA FORM 13036 (REV. 05/11) |