Na Form 13042 PDF Details

In our continuous effort to serve individuals seeking access to medical records, understanding the nuances of the National Personnel Records Center's request process is crucial. The NA Form 13042 plays a pivotal role in this endeavor, acting as a gateway for individuals to request clinical and outpatient records. Designed with precision, this form ensures that people can request medical records for military service members, retirees, and their dependents who have received treatment in military medical facilities. It is imperative to distinguish, however, that this form is not the correct avenue for obtaining outpatient health and dental records created during military service, or for accessing VA hospital records. The guidelines surrounding the form stress the importance of filling it out thoroughly to avoid delays, underscore the voluntary nature of the information provided, yet highlight the potential consequences of incomplete submissions. Sending this form to the correct address is crucial for the timely processing of requests. The form not only serves as a request but also as a form of authorization, making it vital for individuals to understand its scope and limitations. Lastly, adhering to regulations such as the Privacy Act of 1974, the form upholds the confidentiality and privacy of the applicants, ensuring that their information is handled with the utmost care and respect.

QuestionAnswer
Form NameNa Form 13042
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names13042, archives form 13042, national na form, na form 13042

Form Preview Example

OMB No. 3095-0039 Expires 7/31/2014

REQUEST FOR INFORMATION NEEDED TO LOCATE MEDICAL RECORDS

WHEN TO USE THIS FORM: Use this form to request the following categories of medical records from the National Personnel Records Center:

Clinical (inpatient) records for a military service member, a military retiree, or a dependent of an active/retired military member for hospitalization in a military medical treatment facility.

Outpatient records for a military retiree, a dependent of an active/retired military member, a civilian Federal employee, or a dependent of a civilian employee for outpatient treatment in a military medical treatment facility.

WHEN NOT TO USE THIS FORM: Do not use this form to request the following:

Outpatient (health) records and dental records created for a person while in the military service. Request these records by using Standard Form (SF) 180, Request Pertaining to Military Records or online via eVetRecs at www.archives.gov/veterans/military-service-records/.

The SF 180 is available from most VA offices and other organizations that serve veterans and from the web at www.archives.gov/veterans/military-service-records/standard-form-180.html.

VA hospital records. Please phone the VA at 1-800-827-1000 for help in obtaining these records. You will need to provide your VA Claim Number.

HOW TO USE THIS FORM:

Use a separate form for each individual for whom you are requesting records.

Fill in page 2 of this form to the best of your ability.

Please be sure to read the section near the bottom entitled “Authorization To Receive Information From Medical

Records” and obtain the required authorization signature.

WHERE TO SEND THIS FORM:

National Personnel Records Center

Military Personnel Records

1 Archives Drive

St. Louis, MO 63138-1002

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

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 AT THE BOTTOM OF THIS PAGE

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

The following information is provided in accordance with U.S.C. 552a (e)(3) and applies to this form. Authority for collection of the information is 44 U.S.C. 2907, 3101, 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. The purpose of the information on this form is to assist the National Personnel Records Center in locating the correct medical record(s) or information to answer your inquiry. If the requested information is not provided, it may delay servicing your inquiry because the National Personnel Records Center may not have all the information needed to locate the requested record(s). This form is then filed in the requested file as a record of disclosure. The form may also be disclosed to Department of Defense components, Department of Homeland Security (DHS, U.S. Coast Guard) or a civilian agency if the National Personnel Records Center transfers all or part of the medical record to one of these agencies.

Date

Prepared by

AFN

NATIONAL PERSONNEL RECORDS CENTER

Military Personnel Records

1 Archives Drive

St. Louis, MO 63138-1002

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

NA FORM 13042 (Page 1 of 2) (REV. 5/11)

OMB No. 3095-0039 Expires 7/31/2014

REQUEST FOR INFORMATION NEEDED TO LOCATE MEDICAL RECORDS

SECTION I – ABOUT THE PATIENT (Please print or type, but first read the instructions on page 1)

NAME OF PATIENT

at time of treatment:

Last

First

Middle Initial

A.STATUS OF PATIENT AT TIME OF TREATMENT: (Please check appropriate box and fill in information requested on the blank lines)

 

 

MILITARY SERVICE

 

 

Branch of service

 

 

Service number

 

 

SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RETIRED MILITARY SERVICE MEMBER

Branch of service

Service number

SSN

Date retired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT OF MILITARY SERVICE MEMBER

 

Dependent’s date of birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

Sponsor’s

 

 

Name (last, first, middle initial)

 

Branch of service

Service number

SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEDERAL

 

SSN

 

Date of Birth

 

Employment separation date

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT OF

Employee’s name (last, first, middle initial)

 

Employee’s SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

FEDERAL EMPLOYEE

 

 

 

 

 

 

 

 

 

 

OTHER (specify)

 

 

 

 

 

 

 

 

B. INFORMATION AND/OR DOCUMENTS REQUESTED:

C. INFORMATION NEEDED TO LOCATE RECORDS:

If you are requesting inpatient records, please provide each year and military facility where hospitalized.

If you are requesting outpatient records, please provide the last year and military facility where treated.

NATURE OF ILLNESS,

INJURY, OR TREATMENT

TREATMENT DATES

ADMITTED

TREATED

(overnight stay )

(but not admitted)

 

 

(From Mo/Yr)

(To Mo/Yr)

Yes

No

Yes

No

 

 

 

 

 

 

NAME, NUMERICAL DESIGNATION,

AND LOCATION OF HOSPITAL,

DISPENSARY OR MEDICAL

FACILITY

SECTION II – RETURN ADDRESS AND SIGNATURE

1. REQUESTER IS:

Patient identified in Section1A, above

Parent of minor dependent or legal guardian of patient (If guardian, please submit copy of court appointment)

Next of kin of deceased patient (Must provide proof of death) Show relationship:

Other (specify):

2.AUTHORIZATION SIGNATURE REQUIRED (of patient or legal guardian): I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information in Section II is true and correct.

3. SEND INFORMATION/DOCUMENTS TO:

(Please print or type. See eligibility instructions below.)

Name

Signature of patient, next of kin, or legal guardian. DO NOT PRINT.

Street

E-mail address

City

State

ZIP Code

Date

Daytime phone number (including area code)

AUTHORIZATION TO RECEIVE INFORMATION FROM MEDICAL RECORDS

a. Restrictions on release of information: Release of information is subject to restrictions imposed by the military services and civilian agencies consistent with Department of Defense and civilian agency regulations and the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The former patient or the patient’s legal guardian has access to almost any information contained in the patient’s own record. Others requesting information must have the release authorization in Section II,

above, signed by the patient or legal guardian. If the patient is deceased, surviving next of kin may, under certain circumstances, be entitled to these records as well. The next of kin is defined as any of the following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. The next of kin must provide proof of death and show relationship; the legal guardian must provide a copy of the court order proving guardianship or mental incompetence, as appropriate.

b.Where the reply may be sent: The reply may be sent to the patient or any other address designated by the patient or other authorized requester.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

NA FORM 13042 (Page 2 of 2) (REV. 5/11)

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This document will need particular data to be filled out, thus be sure you take whatever time to enter what is required:

1. When filling out the na form download, ensure to complete all of the important fields within its associated part. This will help hasten the work, which allows your information to be handled quickly and accurately.

13042 conclusion process described (portion 1)

2. Your next stage is to fill in these particular blank fields: The following information is, Date, Prepared by, AFN, NATIONAL PERSONNEL RECORDS CENTER, Military Personnel Records, Archives Drive, St Louis MO, and NATIONAL ARCHIVES AND RECORDS.

NATIONAL PERSONNEL RECORDS CENTER, Date, and St Louis MO of 13042

3. In this part, review SECTION I ABOUT THE PATIENT, NAME OF PATIENT at time of, Last, First, Middle Initial, A STATUS OF PATIENT AT TIME OF, MILITARY SERVICE, MEMBER, Branch of service, Service number, SSN, RETIRED MILITARY Branch of service, Service number, SSN, and Name last first middle initial. Every one of these have to be taken care of with highest accuracy.

Stage # 3 of submitting 13042

4. All set to complete the next portion! In this case you have these SECTION II RETURN ADDRESS AND, REQUESTER IS, Patient identified in SectionA, AUTHORIZATION SIGNATURE REQUIRED, Signature of patient next of kin, Email address, Date, Next of kin of deceased patient, Show relationship, Other specify, SEND INFORMATIONDOCUMENTS TO, Name, Street, City State ZIP Code, and Daytime phone number including empty form fields to fill out.

Part number 4 of filling in 13042

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