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The NA Form 13055 is an essential tool for veterans and their families needing to reconstruct medical records that may have been lost or destroyed. Following a devastating fire in 1973 at the National Personnel Records Center, many service members' medical records were damaged or lost, creating challenges for those seeking important health information. This form assists individuals in requesting the information necessary to locate and retrieve medical data from alternative sources. Notably, the form requires detailed information about the service member, including dates of treatment, branch of service, and nature of the illness or injury. It also specifies that the person requesting the information must have appropriate authorization, especially in cases where the veteran is deceased. Additionally, the form outlines alternate sources, such as records from the Department of Veterans Affairs, which may contain pertinent information if a claim was previously filed. Completing the form accurately and providing enough detail is crucial, as it can significantly streamline the process of obtaining the desired medical records. Understanding how to navigate the requirements of the NA Form 13055 can make a vital difference for those seeking clarity about a loved one's medical history.
13055 Example
OMB
REQUEST FOR INFORMATION NEEDED TO RECONSTRUCT
MEDICAL DATA
The medical record needed to answer your request is not in our files. If the record were here on July 12, 1973, it would have been in the area that suffered the most damage in the fire on that date and may have been destroyed.
Some medical records were transferred to the Department of Veterans Affairs, formerly the Veterans Administration (VA), before the 1973 fire. The VA would have obtained the record to process a claim for benefits based on a
If the medical record was not transferred to the VA, there are also some alternate record sources available which often contain information concerning illness or injury while in the military service. One limited source of such information pertains to treatment received primarily at Army hospitals during some years from 1942 through 1954. If such information is available on the person named in this request, it is attached. If such information is not available, or it is attached and you find that it does not meet your needs, we will attempt to use other alternate sources. Please note, however, that these other alternate sources usually show only dates of treatment or hospitalization and rarely show diagnosis or treatment given.
To enable us to search secondary sources, please provide the information requested below. We need to know the exact month(s) as well as the year of treatment; the year alone is not enough. If you don’t know the exact month, then please tell us the season and year.
NAME OF PATIENT USED AT TIME OF TREATMENT |
SERVICE NO. |
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SOCIAL SECURITY NO.
BRANCH OF SERVICE
NATURE OF ILLNESS, INJURY OR TREATMENT
TREATMENT DATES
FROMTO
(MO/YR) (MO/YR)
CHECK ONE
ORGANIZATION TO
WHICH ASSIGNED (Furnish specific units to include company, battalion, regiment,
squadron, group, wing, etc.)
NAME AND LOCATION OF HOSPITAL, DISPENSARY OR MEDICAL FACILITY WHERE TREATED
To provide the information requested we must have the signature of the person whose records are involved. If the person is deceased, the next of kin must sign and provide proof of death and evidence of kinship. For release purposes the next of kin is defined as any of the following: unremarried widow or widower; son or daughter; father or mother; brother or sister. If the person is legally incompetent, the
RELEASE AUTHORIZATION:
I hereby authorize release of the requested information/documents to the person indicated at right.
VETERAN SIGN HERE:
(If signed by other than veteran show relationship to veteran)
DATE OF REQUEST:
Please type or print clearly COMPLETE RETURN ADDRESS (to be mailed to)
(name)
(street number)
(city) |
(state) |
(zip code) |
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Daytime Phone No. with area code ( |
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Date
Prepared by
NATIONAL PERSONNEL RECORDS CENTER
(Military Personnel Records)
1 Archives Drive
St. Louis, MO
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION |
NA FORM 13055 (Page 1 of 2) (REV. 04/11) |
OMB
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 USC 2907, 3101, 3103 and Public Law
answer your inquiry. This form is then filed in the requested military service record as a record of disclosure. The form may be further disclosed with the military record to (1) a “Routine Use” as defined in the Privacy Act of 1974, 5 U.S.C. 552a (a)(7), and as
published by the Department of Defense, the military service departments, and the Department of Homeland Security (DHS, U.S. Coast Guard) in the Federal Register; (2) other individuals or offices who present written authorization of the veteran, the veteran’s next of kin when the veteran is deceased, the veteran’s legal representative officially designated in writing, or a legal guardian when
the veteran has been declared incompetent; or (3) pursuant to the order of a court of competent jurisdiction.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. The information requested on this form is being collected and used by the National Personnel Records Center to identify and locate military service records that could not be identified and located in response to the original inquiry. 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 (NHP), 8601 Adelphi Road, College Park, MD
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION |
NA FORM 13055 (Page 2 of 2) (REV. 04/11) |
Form Characteristics
| Fact Name | Detail |
|---|---|
| Form Identifier | The form is known as NA Form 13055. |
| Federal Oversight | This form is regulated under OMB Control Number 3095-0039. |
| Expiration Date | The form expired on July 31, 2014, but it may still be in use for necessary data collection. |
| Purpose | This form requests information to reconstruct medical data lost in a fire. |
| Authority References | The information is collected under various statutes, including 44 USC 2907 and 5 U.S.C. 552a. |
| Voluntary Disclosure | Providing information is voluntary; however, incomplete submissions may delay processing. |
| Next of Kin Signature | If the veteran is deceased, a next of kin must provide their signature along with proof of death. |
| Contact Information | Individuals should contact their nearest VA facility by calling 1-800-827-1000 for assistance. |
| Data Confidentiality | The Privacy Act of 1974 governs the handling and disclosure of the information provided on this form. |
Guidelines on Utilizing 13055
Completing the 13055 form involves providing necessary details to assist in locating military medical records. Accurate and specific information will help streamline the process and avoid delays.
- Download the form: Obtain the 13055 form from a reliable source, such as the National Archives website.
- Read the instructions: Familiarize yourself with the information you need to provide.
- Fill in patient information: Enter the name of the patient as it was used during the medical treatment.
- Provide service number: Input the military service number of the patient.
- Enter Social Security number: Fill in the patient’s Social Security number.
- Specify branch of service: Indicate which branch of the military the patient served in.
- Detail nature of illness/injury: Clearly describe the medical condition or treatment sought.
- Input treatment dates: Provide the exact dates of treatment using the format (MO/YR).
- Check the appropriate box: Indicate whether the treatment was inpatient or outpatient.
- Complete organization details: Include the specific unit information, such as company or battalion.
- Identify medical facility: State the name and location of the hospital or medical facility.
- Obtain signature: Ensure the signature is from the veteran, next of kin, or legal guardian if necessary.
- Enter date of request: Fill in the date when you are submitting the request.
- Provide return address: Add your name, street address, city, state, and zip code for correspondence.
- Add email address: Enter a valid email address for any necessary follow-up.
- Include daytime phone number: Provide a contact number with area code for reachability.
Once the form is completed, review it carefully for any inaccuracies. Ensure that all required signatures are present before submitting the form to the address provided on the document. Following this procedure will help ensure a smoother process in retrieving the needed records.
What You Should Know About This Form
What is Form 13055 used for?
Form 13055 is a request for information needed to reconstruct medical data related to military service. It helps individuals obtain medical records that may have been lost or destroyed, particularly in the 1973 fire that impacted many records at the National Personnel Records Center.
Who should fill out Form 13055?
The form should be filled out by the person whose records are being requested, or by the next of kin if the individual is deceased. If the individual is legally incompetent, their court-appointed guardian must complete the form.
What information is required on Form 13055?
The form requires details such as the patient's name at the time of treatment, service number, social security number, branch of service, nature of illness or injury, treatment dates, and the name and location of the medical facility where the treatment occurred. Additionally, the signature of the individual or the next of kin is needed for authorization.
What should I do if I do not have the exact dates of treatment?
If the exact month of treatment is not known, the form allows the submission of the season and year instead. The more specific the information provided, the better the chances of accurately locating the requested records.
How can I obtain military medical records if they were transferred to the VA?
If medical records were transferred to the Department of Veterans Affairs (VA), one should contact the nearest VA facility at 1-800-827-1000 to request those records. The VA may retain the necessary documentation to process claims related to service-connected injuries or illnesses.
Are there alternative sources for medical records if Form 13055 does not yield results?
Yes, alternative sources exist that may contain relevant information. These sources often include records from Army hospitals dating from 1942 through 1954. It is important to note that these records typically only provide limited details, such as dates of treatment, rather than in-depth medical information.
What if the requester is not the veteran or next of kin?
If the person filling out the form is not the veteran or their next of kin, they must provide written authorization from the veteran or the appropriate legal representative. This ensures compliance with privacy regulations and protects the rights of the individual whose records are being requested.
Is there a deadline for submitting Form 13055?
There is no specified deadline for submitting Form 13055; however, timely submission is advisable to avoid delays in obtaining the requested information. It is also important to ensure all required information is complete to facilitate the processing of the request.
Why is my signature required on Form 13055?
The signature is a necessary element of the authorization process. It verifies the requester's identity and grants permission for the release of the medical records, thereby protecting sensitive information in accordance with privacy laws.
Common mistakes
Filling out the NA Form 13055, which requests information to reconstruct medical data, can present challenges. Below are common mistakes that individuals often make, which can lead to delays or complications in processing their requests.
One frequent error is incomplete information. Applicants sometimes fail to provide all the required details, such as the exact month and year of treatment. The form explicitly states that the year alone is insufficient. Without complete dates, it becomes difficult for the reviewing agency to locate the necessary records.
Another mistake is unclear handwriting. Since the form must be filled out legibly, any lack of clarity can result in misinterpretation. Illegible handwriting may lead to errors in data entry and ultimately delay the processing of the request.
Many people also neglect to include the signature of the individual whose records are being requested. If the patient is deceased, the next of kin must sign and provide proof of death and relation. Failing to include this essential information can cause an immediate rejection of the request.
Some applicants mistakenly select the wrong type of treatment on the form. The choices between in-patient and out-patient treatment need to be accurately identified. Choosing incorrectly could result in a search of the wrong type of records, further complicating the process.
Additionally, not providing a complete return address can hinder the timely processing of requests. All required information, including the name, street number, city, state, and zip code, must be included to ensure the response is sent to the correct location.
A further complication arises when applicants omit their daytime phone number. Including a contact number is essential for quick communication in case additional information is needed. Without this, the agency may struggle to reach the applicant for clarification.
Finally, individuals often fail to carefully review the instructions before submission. Skimming through the requirements can lead to overlooking important details or failing to understand necessary elements of the form. A thorough review can prevent many common mistakes encountered in the form-filling process.
Documents used along the form
The NA Form 13055 is used to request information to help reconstruct medical records that have been lost, particularly records related to military service. Along with this form, there are several other documents that may be necessary during the process of retrieving military medical data. Each of these forms serves a specific purpose in ensuring that relevant information is gathered for the request.
- NA Form 13042: This form is utilized to request the honorable discharge papers for veterans. It includes details such as service dates, character of service, and the reason for discharge, which can be important when verifying medical histories.
- VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. It prompts veterans to disclose service-related injuries or illnesses, which can assist in locating pertinent medical records.
- SF 180: The Standard Form 180 is used to request military records. It allows veterans or next of kin to specify the types of records needed, helping streamline the retrieval process.
- VA Form 21-22: This form is a designation of a representative for claims assistance. Having a representative can facilitate communication and organization of necessary documents required for making a claim.
- VA Form 21-4142: The Authorization to Disclose Information to the Department of Veterans Affairs form allows the VA to obtain private medical records. This is vital when veterans need their treatment information from non-military sources.
- Next of Kin Documentation: In cases where the veteran is deceased, proof of relationship along with a death certificate is essential. This documentation verifies eligibility for accessing the medical records of the deceased veteran.
Gathering the right forms and documents can expedite the process of reconstructing lost medical data. Each document has its significance in ensuring the accurate retrieval of necessary information for veterans and their families.
Similar forms
- SF 180 - Request Pertaining to Military Records: This form is used to request a veteran's military service records. Similar to the 13055, it helps locate records that may have been destroyed or lost.
- VA Form 21-526EZ - Application for Disability Compensation: This application helps veterans claim benefits. It may require similar information about service and medical history, connecting to prior records retrieval.
- NA Form 13062 - Request for Military Records: Like the 13055, this form requests information on military service records and is crucial for veterans needing assistance with benefits claims.
- VA Form 21-4142 - Authorization to Disclose Information to the Department of Veterans Affairs: This document allows the VA to obtain medical records from other sources, paralleling the 13055's purpose of locating medical information.
- DD Form 214 - Certificate of Release or Discharge from Active Duty: This form provides official discharge information and is often needed alongside the 13055 to verify a veteran’s service.
- VA Form 22-5500 - Application for Educational Assistance: This form is used by veterans seeking education benefits and may reference prior military medical records as part of the application process.
- Federal Employee Health Benefits (FEHB) Enrollment Form: This form permits federal employees to enroll in health benefits. Similar information about health status may be required.
- NA Form 13053 - Application for Search of Military Records: Also serving to locate military records, this form collects essential details similar to those requested on the 13055.
- SF 86 - Questionnaire for National Security Positions: This form collects personal information, including medical history, which can relate to military service records.
- VA Form 21-0779 - Request to Discharge a Veteran from a Care Facility: This form may involve retrieving medical information for processing, echoing the records retrieval aspect of the 13055.
Dos and Don'ts
When filling out the NA Form 13055, there are important steps to follow to ensure the process goes smoothly. The following list includes things you should do and avoid.
- Do provide accurate information: Ensure all details, such as the patient’s name and service number, are correct.
- Do specify treatment dates: Include exact months and years of treatment to help locate the records.
- Do include signature: The request must be signed by the person whose records are involved, or their next of kin, if applicable.
- Don't leave blanks: Incomplete forms can delay processing. Fill out all applicable sections.
- Don't forget proof of death: If the patient is deceased, provide documentation to establish the next of kin’s authority to request the records.
- Don't submit the form without a return address: Ensure you include a complete return address so the requested information can be sent to you.
By adhering to these guidelines, the likelihood of a timely and accurate response will increase, helping you obtain the necessary information with less frustration.
Misconceptions
The 13055 form, used for requesting information related to reconstructing medical data, is often misunderstood. Here are some common misconceptions:
- The 13055 form guarantees that records will be found. The form is not a guarantee that your medical records are available, especially if they were destroyed in a fire.
- Information can be requested without proper authorization. A signature is required from the patient or their legal representative to release medical records.
- Any family member can request information on behalf of the veteran. Only specific relatives, such as a spouse or child, have the authority to request records if the veteran is deceased.
- Providing just the year of treatment is sufficient. You must supply the exact month and year of treatment. Without the month, the request may be delayed.
- The VA automatically has all medical records. Not all medical records were transferred to the Department of Veterans Affairs prior to the 1973 fire, so this is not a reliable source.
- All records contain detailed treatment information. Alternative sources may only provide dates of treatment, lacking diagnosis or details on the care provided.
- If a record is lost, it cannot be reconstructed. There are alternative sources available to help reconstruct medical history, even if the records are not accessible.
- The process is quick and straightforward. The request process can take time, particularly if detailed information is missing or if additional documentation is needed.
- The 13055 form is only for veterans. It can also be used by next of kin or legal representatives to access records of deceased veterans.
Understanding these misconceptions can help ensure a smoother experience when requesting medical records using the 13055 form.
Key takeaways
Filling out and using Form 13055 can feel overwhelming, but understanding the key points can make the process smoother. Here are some essential takeaways to keep in mind:
- Purpose of the Form: Form 13055 is used to request information needed to reconstruct medical data that may have been lost due to a fire in 1973.
- Contact the VA: If you believe your medical record was sent to the Department of Veterans Affairs before the fire, reach out to them at 1-800-827-1000 to request your information.
- Alternate Sources: If documents were not transferred to the VA, there are alternative sources, though they may only offer limited information related to treatment dates or hospitalization.
- Provide Specific Dates: The form requires exact months and years for any medical treatment, as just providing a year is insufficient for the search.
- Signature Requirements: The individual whose records are requested must sign the form. If they are deceased or legally incompetent, the next of kin or guardian must sign and include supporting documents.
- Complete Return Address: Ensure the return address is complete and clear to avoid delays in receiving the requested information.
- Data Privacy: Your information is shared in compliance with privacy laws. It’s important to understand that disclosure is voluntary but necessary for processing your request efficiently.
Keeping these points in mind will help make your experience with Form 13055 easier and ensure that you gather the necessary information correctly.
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