Form 13042 Request for Information Needed to Locate Medical Records

OMB No. 3095-0039 Expires XX/XX/XXXX
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 http://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 (MP), 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.
				     
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				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. 03/17)

OMB No. 3095-0039 Expires xx/xx/xxxx

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

Date of Birth      

SSN      

     

     

  

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

MILITARY SERVICE

SSN

Branch of service

Service Number

MEMBER

     

     

     

RETIRED MILITARY

SSN

Branch of service

Service Number

Date Retired

SERVICE MEMBER

     

     

     

     

DEPENDENT OF MILITARY SERVICE MEMBER

Sponsor’s Name (last, first, middle initial)

SSN

Branch of service

Service Number

     

     

     

     

FEDERAL EMPLOYEE OR DEPENDENT OF FEDERAL EMPLOYEE

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

SSN

Date of Birth

Separation Date

     

     

     

     

B. INFORMATION AND/OR DOCUMENTS REQUESTED:

     

C. INFORMATION NEEDED TO LOCATE RECORDS: (Complete the applicable lines below only for the records you are requesting.)

Inpatient Records

NAME & LOCATION OF MILITARY FACILITY WHERE TREATMENT WAS RECEIVED

TREATMENT DATES

NATURE OF ILLNESS, INJURY, OR TREATMENT

From Mo/Yr

To Mo/Yr

     

     

     

     

     

     

     

     

     

     

     

     

Outpatient Records

NAME & LOCATION OF THE LAST MILITARY FACILITY PROVIDING OUTPATIENT TREATMENT FOR ANY CONDITION

LAST YEAR TREATED FOR ANY OUTPATIENT CONDITION

LOCATION & YEAR FOR OUTPATIENT TREATMENT AT A PREVIOUS FACILITY (Optional - May help locate records that did not transfer)

     

     

     

SECTION II – RETURN ADDRESS AND SIGNATURE

1. REQUESTER IS:

Patient identified in Section1A, above

Next of kin of deceased patient (Must provide proof of death)

Parent of minor dependent or legal guardian of patient

Show relationship:

     

(If guardian, please submit copy of court appointment)

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. 03/17)