Form 13177 Form 13177 Follow-up to Request for Clinical & Medical Treatment Re

NATIONAL PERSONNEL RECORDS CENTER
1 ARCHIVES DRIVE ST. LOUIS, MO 63138-1002

OMB Control No. 3095-0039
Expires 07/31/2017

Follow-up to Request for Clinical & Medical Treatment Records
This form is ONLY for status updates for EXISTING requests. Instructions on how to initiate a
new request can be found at http://www.archives.gov/veterans/military-service-records/
Top of Form

Requester Information
* Requester Name:

Last Name Required

First Name Required

* Postal/Zip Code:
* Phone:

Phone# 000-000-0000

Email:

EXAMPLE:
Clinical & Medical
Treatment Records
Web Form

Extn:
Confirm Email:

Sponsor (Veteran) Information
* Veteran’s Name:

Last Name Required

* Veteran’s SSN
(Last 4 Digits):
Branch of Service:

First Name Required

Middle Name Optional

Why we collect this information
DROP DOWN BOX

Patient (Dependent or Veteran) and Request Information
* Patient’s Name:

Last Name Required

* Patient’s SSN
(Last 4 Digits):
Request #:

First Name Required

Middle Name Optional

Why we collect this information
Optional

Military Treatment
Facility Name:

Optional

Additional Comments
Additional
Comments:

Form Actions
REVIEW ENTRIES

Your information will not be submitted yet, and you will be able to return to this page to make revisions.

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 facility servicing the service member's record may not have all of the information
needed to locate it. The purpose of the information on this form is to assist the facility servicing the records (see the address list) in locating the correct military service record(s) or information to answer your inquiry. This form is then
retained as a record of disclosure. The form may also be disclosed to Department of Defense components, the Department of Veterans Affairs, the Department of Homeland Security (DHS, U.S. Coast Guard), or the National Archives and
Records Administration when the original custodian of the military health and personnel records transfers all or part of those records to that agency. If the service member was a member of the National Guard, the form may also be disclosed
to the Adjutant General of the appropriate state, District of Columbia, or Puerto Rico, where he or she served.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
Public burden reporting for this collection of information is estimated to be two minutes per request, 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 (ISSD), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND
COMPLETED FORMS TO THIS ADDRESS.

NA Form 13177 (10-14)

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

Prescribed by NARA (xx CFR xxxx.xx(x))