Form NA-13036 Authorization for Release of Military Medical Patient Re

OMB No. 3095-0039 Expires xx/xx/xxxx
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 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE ADDRESS SHOWN BELOW. 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 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 cannot release the information described above. The purpose of the information on this form is to ensure that National Personnel Records Center has the specific authority to release the information in the records described above. This form is then filed in the requested military service record as a record of disclosure. The form may be disclosed to the Department of Defense components or the Department of Homeland Security (DHS, U.S. Coast Guard), if the National Personnel Records Center transfers all or part of those records to such agency. If the service member was a member of the National Guard, the form may be disclosed to the Adjutant General of the appropriate state, District of Columbia, or Puerto Rico, where he or she served. The form may also be disclosed when the military service member or, in the case of a deceased service member, the military service department, authorizes a specific individual or organization to have access to the military service record.
							     
	     
							Date      
						Prepared by      
						NRPM    
						NATIONAL PERSONNEL RECORDS CENTER (Military Personnel Records) 9700 Page Avenue St. Louis, MO 63132-5100

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA FORM 13036 (REV. 12/05)