DD Form 2963 Service Treatment Record (Str) Certification

What Is DD Form 2963?

DD Form 2963, Service Treatment Record Certification is a form used for indicating that a Service Treatment Record (STR) folder in an electronic record archive is complete. When archiving the STR, this record is the last document to be uploaded.

An up-to-date DD Form 2963 fillable version is available for digital filing and download below or can be found through the Executive Services Directorate website.

The information provided on the form will be forwarded to the Department of Veterans Affairs (VA) for processing potential claims and is protected under the Health Insurance Portability and Accountability Act and the Privacy Act of 1974.

The latest edition of the DD 2963 - sometimes incorrectly referred to as the DA Form 2963 - was released by the Department of Defense (DoD) in March 2014 with all previous editions being obsolete.

ADVERTISEMENT
SERVICE TREATMENT RECORD (STR) CERTIFICATION
(Read Instructions on back before completing form.)
TO:
1. DATE OF CERTIFICATION
(YYYYMMDD)
Veterans Benefits Administration,VA Regional Office
2. FROM
(Sending Organization and complete mailing address)
This information is made available to Department of Veterans Affairs (VA) for utilization in potential claims processing.
Please utilize information as appropriate.
The information herein is For Official Use Only (FOUO) and must be protected under the Privacy Act of 1974 and the Health
Insurance Portability and Accountability Act (HIPAA). These records should be handled with confidentiality to ensure the
veteran/patient's privacy. Unauthorized disclosure or misuse of this personal information may result in criminal and/or civil
penalties.
3. SERVICE MEMBER IDENTIFICATION
a. NAME
b. SSN (Last 4 digits)/DoD ID NO.
(Last, First, Middle Initial)
4. CERTIFICATION
0
(Insert type of document.)
A thorough review of all known DoD or United States Coast Guard (USCG) systems, as appropriate, has been accomplished as
directed by DoDI 6040.45. As such, other than the records being enclosed herein, it has been concluded that no further records
exist for the service member, and the STR is complete as of the certification date of this form. In the event additional
documentation is discovered, it will immediately be made available to VA for utilization in potential claims processing.
COMMENTS:
**NOTE: If separating member has served less than 180 days, enter "Entry Level Separation" in comments area below.
5. OFFICE OF PRIMARY RESPONSIBILITY
a. OFFICE NAME AND ADDRESS
b. POINT OF CONTACT NAME
(Last, FIrst, Middle Initial)
d. TELEPHONE NUMBER
c. EMAIL ADDRESS
(Include Area Code/DSN)
DD FORM 2963, MAR 2014
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0
SERVICE TREATMENT RECORD (STR) CERTIFICATION
(Read Instructions on back before completing form.)
TO:
1. DATE OF CERTIFICATION
(YYYYMMDD)
Veterans Benefits Administration,VA Regional Office
2. FROM
(Sending Organization and complete mailing address)
This information is made available to Department of Veterans Affairs (VA) for utilization in potential claims processing.
Please utilize information as appropriate.
The information herein is For Official Use Only (FOUO) and must be protected under the Privacy Act of 1974 and the Health
Insurance Portability and Accountability Act (HIPAA). These records should be handled with confidentiality to ensure the
veteran/patient's privacy. Unauthorized disclosure or misuse of this personal information may result in criminal and/or civil
penalties.
3. SERVICE MEMBER IDENTIFICATION
a. NAME
b. SSN (Last 4 digits)/DoD ID NO.
(Last, First, Middle Initial)
4. CERTIFICATION
0
(Insert type of document.)
A thorough review of all known DoD or United States Coast Guard (USCG) systems, as appropriate, has been accomplished as
directed by DoDI 6040.45. As such, other than the records being enclosed herein, it has been concluded that no further records
exist for the service member, and the STR is complete as of the certification date of this form. In the event additional
documentation is discovered, it will immediately be made available to VA for utilization in potential claims processing.
COMMENTS:
**NOTE: If separating member has served less than 180 days, enter "Entry Level Separation" in comments area below.
5. OFFICE OF PRIMARY RESPONSIBILITY
a. OFFICE NAME AND ADDRESS
b. POINT OF CONTACT NAME
(Last, FIrst, Middle Initial)
d. TELEPHONE NUMBER
c. EMAIL ADDRESS
(Include Area Code/DSN)
DD FORM 2963, MAR 2014
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0
INSTRUCTIONS FOR COMPLETING DD FORM 2963,
SERVICE TREATMENT RECORD (STR) CERTIFICATION
(See DoDI 6040.45)
BLOCK 1. DATE OF CERTIFICATION (YYYYMMDD).
Enter date of certification.
BLOCK 2. FROM (Sending Organization and Complete Mailing Address).
Enter sender's or Command address.
BLOCK 3. SERVICE MEMBER INFORMATION.
3.a. NAME (Last, First, Middle Initial). Enter Service member's legal name.
3.b. SSN (Last 4 digits)/DoD ID No. Enter the last 4 digits of Service member's SSN, or DoD Identification Number.
If Certifying a Complete STR:
BLOCK 4. CERTIFICATION. Select "Complete STR (Medical and Dental)."
COMMENTS. Enter comments as needed.
NOTE: Select Complete STR (Medical and Dental) if the records are consistent with requirements for an STR as directed by
DoDI 6040.45.
If Certifying Medical Records Only:
BLOCK 4. CERTIFICATION. Select "Medical Record."
COMMENTS. Enter comments as needed.
NOTE: If separating member has served less than 180 days, enter "Entry Level Separation" in Comments area.
If Certifying Dental Records Only:
BLOCK 4. CERTIFICATION. Select "Dental Record."
COMMENTS. Enter comments as needed.
NOTE: If separating member has served less than 180 days, enter "Entry Level Separation" in Comments area.
BLOCK 5. OFFICE OF PRIMARY RESPONSIBILITY.
Enter requested information of the Office of Primary Responsibility or Point of Contact (POC):
5.a. Enter name and address of Medical Treatment Facility (MTF) or Dental Treatment Facility (DTF).
5.b. POINT OF CONTACT NAME (Last, First, Middle Initial). Enter POC name.
5.c. EMAIL ADDRESS. Enter POC email address.
5.d. TELEPHONE NUMBER (Include Area Code). Enter commercial telephone number of MTF or DTF.
DD FORM 2963 (BACK), MAR 2014

Download DD Form 2963 Service Treatment Record (Str) Certification

651 times
Rate
4.8(4.8 / 5) 45 votes
ADVERTISEMENT

How to Fill Out DD Form 2963?

Additional guidelines and filing information and see the Department of Defense Instruction Number 6040.45 released on November 16, 2015. DD Form 2963 instructions are as follows:

  1. The date of certification should be specified in Block 1;
  2. The complete mailing address of the sender or command should be provided in Block 2;
  3. Block 3 is for providing personal identifying information about the service member. This includes their legal name and the last four digits of their Social Security Number (SSN) or DoD ID Number;
  4. Block 4 is a drop-down list with three document types to choose from. Additional comments may be provided in the space below the drop-down list, if necessary. The provided options include:
    • A complete STR (Medical and Dental);
    • A medical record;
    • A dental record.
  5. Block 5 - Office of Primary Responsibility - requires information about the Office of Primary Responsibility or Point of Contact (POC). This includes the name and address of the Medical Treatment Facility (MTF) or Dental Treatment Facility (DTF), the name of the POC and the commercial number of the MTF or DTF.
Page of 2