For 13177 Check the Status of a Clinical & Medical & Treatment Rec

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

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

Check the Status of a Clinical & Medical Treatment Records Request
This form is ONLY for status updates for EXISTING requests. Instructions on how to initiate a new request can be found
in the Veterans Section.

Requester Information.
* Requester Name: YOUR LAST NAME

(* = Required)

YOUR FIRST NAME

* Postal/Zip Code: Zip Code
* Phone: Phone # 000-000-0000

Extn:

Extension

Email: Enter for a copy of this request (optiona Confirm your email address

Sponsor (Veteran) Information.
* Veteran's Name: LAST NAME

FIRST NAME

MI.

* Last 4 of SSN: Last 4 digits of SSN Why we collect this information



* Branch of Service: - select branch -

Patient (Dependent or Veteran) and Request Information.
* Patient's Name: PATIENT LAST NAME

PATIENT FIRST NAME

MI.

* Last 4 of SSN: Last 4 digits of SSN Why we collect this information
Request #: Request Number
Military Treatment Military Treatment Facility Name
Facility:

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.

National Archives and Records Administration
NA Form 13177 (xx-xx)
Prescribed by NARA (36 CFR 1233.18(d))

https://www.archives.gov/forms/st-louis/clinical-followup.html

3/31/2017