DD Form 877-1 Request for Medical/Dental Records From the National Personnel Records Center

DD Form 877-1 - also known as the "Request For Medical/dental Records From The National Personnel Records Center" - is a United States Military form issued by the Department of Defense.

The form - often incorrectly referred to as the DA form 877-1 - was last revised on April 1, 1998. Download an up-to-date fillable PDF version of the DD 877-1 below or request a copy through the chain of command.

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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
3. YEAR OF TREATMENT
(IP records - only one year per request.
All others - only last year of treatment)
5. DISEASE OR INJURY
6. STATUS AT TIME OF
7. IDENTIFIERS (Provide information as appropriate on line a., b., c., or d./e.,
8. TYPE OF TREATMENT
TREATMENT (X one)
(X one per request)
according to status selected.)
(1) SSN
(2) SN (If applicable)
INPATIENT
a. MILITARY
HEALTH RECORD
(3) BRANCH OF SERVICE (At time of
(4) DATES OF SERVICE (Including reserve duty)
DENTAL
treatment)
PSY/CONSULTATION
(1) SSN
(2) SN (If applicable)
INPATIENT
b. RETIRED MILITARY
OUTPATIENT
(3) BRANCH OF SERVICE (At time of
(4) DATE RETIRED (YYYYMMDD)
DENTAL
treatment)
PSY/CONSULTATION
(1) SPONSOR'S SSN
(2) SPONSOR'S NAME (Last, First, Middle Initial)
INPATIENT
c. DEPENDENT
OUTPATIENT
(3) OTHER DEPENDENT INFORMATION
DENTAL
PSY/CONSULTATION
(1) SSN
(2) DATE OF BIRTH (YYYYMMDD)
INPATIENT
d. FEDERAL EMPLOYEE
OUTPATIENT
(3) OTHER FEDERAL EMPLOYEE INFORMATION
DENTAL
e. OTHER
PSY/CONSULTATION
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:
9700 PAGE AVE., ST. LOUIS, MO 63132-5100
13. REMARKS
(7) SIGNATURE
(7) SIGNATURE
(8) DATE SIGNED (YYYYMMDD)
(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
Reset
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
3. YEAR OF TREATMENT
(IP records - only one year per request.
All others - only last year of treatment)
5. DISEASE OR INJURY
6. STATUS AT TIME OF
7. IDENTIFIERS (Provide information as appropriate on line a., b., c., or d./e.,
8. TYPE OF TREATMENT
TREATMENT (X one)
(X one per request)
according to status selected.)
(1) SSN
(2) SN (If applicable)
INPATIENT
a. MILITARY
HEALTH RECORD
(3) BRANCH OF SERVICE (At time of
(4) DATES OF SERVICE (Including reserve duty)
DENTAL
treatment)
PSY/CONSULTATION
(1) SSN
(2) SN (If applicable)
INPATIENT
b. RETIRED MILITARY
OUTPATIENT
(3) BRANCH OF SERVICE (At time of
(4) DATE RETIRED (YYYYMMDD)
DENTAL
treatment)
PSY/CONSULTATION
(1) SPONSOR'S SSN
(2) SPONSOR'S NAME (Last, First, Middle Initial)
INPATIENT
c. DEPENDENT
OUTPATIENT
(3) OTHER DEPENDENT INFORMATION
DENTAL
PSY/CONSULTATION
(1) SSN
(2) DATE OF BIRTH (YYYYMMDD)
INPATIENT
d. FEDERAL EMPLOYEE
OUTPATIENT
(3) OTHER FEDERAL EMPLOYEE INFORMATION
DENTAL
e. OTHER
PSY/CONSULTATION
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:
9700 PAGE AVE., ST. LOUIS, MO 63132-5100
13. REMARKS
(7) SIGNATURE
(7) SIGNATURE
(8) DATE SIGNED (YYYYMMDD)
(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
Reset
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
OTHER MEDICAL RECORDS - Outpatient, dental,
NPRC will accept from military facilities for retired
psychiatric, and consultation records are generally
medical treatment records. Read the information
cumulative. A record may contain documents
below before completing the front of this form.
covering several years from several facilities. When
these records reach inactive status, they are
1. Please check to make sure that records from
generally retired and identified by the facility at
recent years have been retired to NPRC before
which the patient was last treated or stationed.
preparing this form. Most inactive records are
Requests for outpatient, dental, psychiatric, or
held at the military treatment facility 1 to 5 years
consultation records, therefore, must include the
after the end of the treatment year before
type of record being requested, the facility and last
retirement. See paragraph 6 below for additional
year of treatment.
information. For recent records, contact the
Records Management Officer of the related facility
to find out if records have been retired, if they are
Please be aware that reassignments after last
in a records holding area, or are still at the facility.
treatment may result in records (outpatient, dental,
psychiatric, and consultation) being transferred to
2. Prepare the request form in triplicate.
and retired from other military treatment facilities. If
no treatment was received at the medical facility at
3. TO EXPEDITE THE RECEIPT OF RECORDS,
the place of final assignment, please write the name
YOU MUST COMPLETE ITEMS 1 THROUGH 11
and location of that facility and the year departed in
AND ITEM 14. Incomplete forms will be returned.
Item 10, "Remarks."
4. This form is authorized for use by military
7. Send the original and first copy of the completed
medical treatment facilities ONLY. Do not
form to the NPRC location indicated below which
distribute to individuals for personal use.
maintains the records you are requesting. Retain the
5. All entries relate to a patient AT TIME OF
third copy for your files.
TREATMENT.
For military (active duty and retired) treated at
6. Submit one form per patient, per type and year
Army, Air Force, and Navy medical treatment
of records requested.
facilities; and dependent and other non-military
personnel treated at Navy medical treatment
INPATIENT RECORDS - Inpatient (clinical) records
facilities:
generally contain documentation of treatment
during a single calendar year. These records are
NATIONAL PERSONNEL RECORDS CENTER
normally retired and identified by the hospital
ATTN: ORGANIZATIONAL RECORDS
which created them. Requests for inpatient
9700 PAGE AVENUE
records must include the facility name and year of
treatment.
ST. LOUIS, MO 63132-5100
HEALTH RECORDS - NPRC maintains health
For dependent and other non-military personnel
records for all U.S. Coast Guard and for military
treated at Army and Air Force medical treatment
personnel separated from service prior to the
facilities:
following dates: Army - October 16, 1992; Air
Force - May 1, 1994; Navy - January 31, 1994;
NATIONAL PERSONNEL RECORDS CENTER
and Marine Corps - May 1, 1994. After these
ATTN: REFERENCE SERVICE BRANCH
dates, the health records are maintained by:
111 WINNEBAGO STREET
ST. LOUIS, MO 63118
DEPARTMENT OF VETERANS AFFAIRS
RECORDS MANAGEMENT CENTER
8. Please enter the return address completely and
P.O. BOX 5020
ST. LOUIS, MO 63115
legibly on the original and copy of the request.
DD FORM 877-1 (BACK), APR 1998

Download DD Form 877-1 Request for Medical/Dental Records From the National Personnel Records Center

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