3. YEAR OF TREATMENT
(IP records - only one year per request.
All others - only last year of treatment)
9700 PAGE AVE., ST. LOUIS, MO 63132-5100
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)
4. NAME OF FACILITY WHERE PATIENT WAS TREATED
5. DISEASE OR INJURY
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:
13. REMARKS (7) SIGNATURE
(8) DATE SIGNED (YYYYMMDD)
(7) SIGNATURE
(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
6. STATUS AT TIME OF
TREATMENT (X one)
a. MILITARY
b. RETIRED MILITARY
c. DEPENDENT
d. FEDERAL EMPLOYEE
e. OTHER
7. IDENTIFIERS (Provide information as appropriate on line a., b., c., or d./e.,
according to status selected.)
(1) SSN (2) SN (If applicable)
(1) SSN
(1) SPONSOR'S SSN
(1) SSN
(2) SN (If applicable)
(2) SPONSOR'S NAME (Last, First, Middle Initial)
(2) DATE OF BIRTH (YYYYMMDD)
(3) BRANCH OF SERVICE (At time of
treatment)
(3) BRANCH OF SERVICE (At time of
treatment)
(3) OTHER DEPENDENT INFORMATION
(3) OTHER FEDERAL EMPLOYEE INFORMATION
(4) DATES OF SERVICE (Including reserve duty)
(4) DATE RETIRED (YYYYMMDD)
8. TYPE OF TREATMENT
(X one per request)
INPATIENT
HEALTH RECORD
DENTAL
PSY/CONSULTATION
INPATIENT
OUTPATIENT
DENTAL
PSY/CONSULTATION
INPATIENT
OUTPATIENT
DENTAL
PSY/CONSULTATION
INPATIENT
OUTPATIENT
DENTAL
PSY/CONSULTATION
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DD FORM 877-1 (BACK), APR 1998
INSTRUCTIONS FOR REQUESTING MEDICAL TREATMENT RECORDS FROM THE NATIONAL PERSONNEL
RECORDS CENTER (NPRC), ST. LOUIS, MO
DD Form 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.