1. Purpose. This memorandum issues and transmits instructions on requests involving health records of former military members.

2. Cancellation. NPRC 1865.103 is canceled.

3. Applicability. The provisions of this memorandum apply to all personnel in reference service operations.

4. Reason for revision. This memorandum updates: references to forms; addresses and routing symbols; and procedures used in processing requests for health records of former military members. This revision separates instructions for requests involving the health records of former military members from those requests involving records created at military medical facilities.

5. Instructions. Instructions for processing requests for health records of former military members are contained in the Attachment. Because of its length, the material is divided into chapters. A Table of Contents is included for convenience. This memo is NOT intended to provide processing instructions for requests for medical records from the Department of Veterans Affairs (VA). For detailed instructions, technicians should consult the latest revision of NPRC 1865.38, Answering VA Form 3101 requests. In addition, most information and instructions related to inpatient (hospital/clinical) records and medical treatment records of dependents and military retirees created at military medical facilities have been removed from this instruction and placed in NPRC 1865.121, Requests involving records created at military medical facilities.

6. Forms. This memorandum provides for the use of the following forms.

NA Form 13008, Loan or Transfer of Records
NA Form 13017, Reply to Medical Records/X-ray Requests
NA Form 13027, Court Order Requirements
NA Form 13036, Authorization for Release of Military Medical Patient Records
NA Form 13040A, Authentication Certificate (CPR)
NA Form 13040B, Authentication Certificate (MPR)
NA Form 13042, Request for Information Needed to Locate Medical Records
NA Form 13042B, Request for Medical/Dental Records and Other Information
NA Form 13051, Transmittal
NA Form 13053, NPRC Acknowledgement/Referral
NA Form 13060, Referral
NA Form 13062, Release of Information
NA Form 13078, Preliminary Form for Release of Military Medical Patient Records
NA Form 13098, NPRC Routing Slip
NA Form 13104, Multiple Purpose Correspondence Form
NA Form 13105, NPRC Search Request and Reply
DA Form 2985-1R, Alcohol and Drug Abuse Control Program Admission Information
DA Form 2985-2R, Individual Patient Data System Alcohol and Drug Abuse Control
                                  Program Intake Record
DA Form 2985-3R, Individual Patient Data System Alcohol and Drug Abuse Control
                                  Program Follow-up Record
DA Form 4465, ADAPCP Military Client Intake and Follow-up Record
DD Form 481, Clinical Record Cover Sheet
DD Form 877, Request for Medical/Dental Records or Information
DD Form 1141, Record of Exposure to Occupational Ionizing Radiation
Standard Form 88, Report of Medical Examination
Standard Form 180, Request Pertaining to Military Records
Standard Form 502, Clinical Record Narrative Summary
Standard Form 513, Clinical Record Consultation Sheet
Standard Form 520, Electrocardiographic Record
Standard Form 600, Chronological Record of Medical Care
VA Form 3101, Request for Information
 

DAVID L. PETREE
Director

 SUBJECT: Requests involving health records of former military members.

1. Purpose. This memorandum transmits revised pages to NPRC 1865.103A.

2. Explanation of change. This memorandum has been updated to show that effective April 1, 1998, the U.S. Coast Guard began retiring USCG health records to the VA, Records Management Center.

3. Instructions. Remove pp. 5/6 of ch. 1, and insert revised pages.
 

DAVID L. PETREE
Director

SUBJECT: Requests involving health records of former military members.

1. Purpose. This memorandum transmits revised pages to NPRC 1865.103A.

2. Explanation of change. This memorandum has been updated to show a change in processing requests for Navy medical records.

3. Instructions.

     a. Remove pp. 5 thru 7 of ch. 1 and insert revised pages.

     b. Remove pp. 1/2 of ch. 2 and insert revised pages.
 

DAVID L. PETREE
Director

1. Background and location of medical records. The medical records stored at NPRC fall into three major categories. These are: health records for former military personnel while on active duty; clinical (hospital inpatient) records of former military personnel while on active duty; and medical treatment records of dependents and military retirees created at military medical facilities. See app. 1-A for the background and locations of medical records stored at NPRC and at the VA, Records Management Center (RMC) (formerly SMRC).

2. Health records.  The health records of former military members while on active duty are normally filed in a health jacket within the Official Military Personnel Folder (OMPF). (EXCEPTION: Navy and Marine Corps records. See ch. 2.) Health records cover outpatient, dental, and mental health treatment (for Navy only) which a former member received while in the military service. Health record documents include induction and separation physical examinations and routine medical care (doctor/dental visits, lab tests, etc.) when the patient was NOT admitted to a hospital. The health records were formerly retired to NPRC with the personnel record portion when a member was discharged or retired from service.

NOTE: Since the early 1990's most of these records are retired directly to the VA, RMC.  See par. 13.

3. X-rays.  The types of x-rays most likely to be available for members of the military services are: entrance and separation x-rays, which are maintained at CPR; and dental x-rays, which are found in most health jackets. X-rays taken for specific reasons between the time of entry on active duty and the time of separation (interim x-rays) are generally maintained by the facility at which treatment occurred and are destroyed after five years. Due to base closures, CPR may have received a shipment of interim x-rays from a closing facility. Consult NPRC 1865.121 to identify closed or pending closed bases/facilities. Also, interim x-rays are sometimes found in Navy/Marine Corps medical jackets.

4. Release of information.

     a. General.  The release of information from and photocopies of military medical records is governed by special agreement between the Department of Defense and the National Archives and Records Administration. The specific items of the agreement are set forth in the latest revision of NPRC 1865.16, Release and Access Guide for Military Records.

NOTE: Refer to ch. 3 for requests pertaining to drug/alcohol abuse patient records, Family Advocacy Program (FAP) records, and other records of a confidential nature.

     b. Proper authorization not received.  If proper authorization is not received, return the inquiry using NA Form 13017, Reply to Medical Records/X-ray Requests, checking the block that states, "Under the provisions of the Privacy Act of 1974...", or NA Form 13062, Release of Information, checking the appropriate block(s).

5. Accounting of disclosure.  See the latest revision of NPRC1864.102, Privacy Act implementation in NPRC reference service operations, for an explanation of this requirement of the Privacy Act of 1974. NPRC branch personnel fulfill the requirement to keep an accounting of the disclosure by retaining a copy of the request and authorization in the record, along with the copy of our reply.

6. Sources of requests.  Requests for health records are primarily received from the following sources:

     a. Veteran, next of kin, or legal guardian;

     b. Members of Congress;

     c. Veteran's attorney;

     d. State, county, and municipal hospitals, health departments, and medical research facilities;

     e. Private nongovernmental medical or psychiatric institution or professional practitioner;

     f. Insurance firms, investigative agencies, and probation and parole officers;

     g. Prospective employers and recruiters;

     h. Department of Veterans Affairs (VA) (See the latest revision of NPRC 1865.38, Answering VA Form 3101 requests, fig. 3, rule 19.);

     i. Social Security Administration and Department of Health and Human Services; and

     j. Military medical treatment facilities.

7. Form of request.  Request forms will vary with the type of requester; e.g., letter, SF 180, Request Pertaining to Military Records, VA Form 3101, Request for Information, and DD Form 877, Request for Medical/Dental Records or Information.

8. Responsibility.

     a. Health records.  The Special Inquiries Section and all correspondence sections, excluding NRPMR-O, are responsible for responding to routine requests for health records and inquiries involving a combination of military personnel, health, AND clinical records.

     b. Clinical records.  Routine requests for clinical records are handled by Records Reconstruction Branch, Correspondence Section 2, (NRPMR-O) at MPR; and Reference Service Branch, Personnel Reference Service Section, (NRPCR-P) at CPR.

     c. Combination of military personnel, health, and clinical records.  If the request involves MPR operations only, the correspondence technician works the case to the extent possible, requests a search of organizational records from NRPMR-O, and places the case in suspense until a reply is received from NRPMR-O. The correspondence technician is responsible for ensuring all necessary information is furnished in order to conduct the organizational records search (see par. 9, below).

     d. Requests involving records at MPR & CPR.  If the request involves both MPR and CPR operations, the technician works the case and completes the appropriate response form to the extent possible. Forward the request with color code tag attached, response form, and copies of the requested documents to NRPCR-P for completion of the case using NA Form 13104, Multiple Purpose Correspondence Form. File a copy of all correspondence in the record. The technician is responsible for ensuring all necessary information is furnished on NA 13104 in order to conduct the organizational records search (see par. 9, below).

EXCEPTION: If the request is for certified/authenticated copies, the technician processing the request brings this fact to the attention of the supervisor who telephones NRPCR-P. The inquiry is suspended and a delay notice sent, if appropriate. When the documents arrive from CPR, the entire group of medical records is assembled at MPR and one certification is made.

9. Information vital for search.

     a. Health records.  Generally the same items of information needed to locate a military personnel record will be required for a search for a veteran's health record; i.e., full name, service/social security number, and branch and dates of service.

     b. Inpatient and outpatient records.  The items of information needed to locate inpatient, outpatient, and mental health records (for Army and Air Force only) are: name of patient at time of treatment; the veteran's/sponsor's social security number; dates of treatment; and place of treatment; i.e., the name of the facility or the numerical designation; e.g., 102nd Evacuation Hospital, and the city/country of the treatment facility, (for outpatient records the last date and place of treatment is needed); status at time of treatment; e.g., active duty or retired; and name of sponsor (if requesting dependent medical records).

     c. Positive PRS probes.  For requests involving inpatient treatment only, if the place of treatment, patient's name, and veteran's/sponsor's SSN are provided, and the date of treatment appears to be 1965 to the present, probe the Patient Retrieval System (PRS) (see NPRC 1865.121, subpar. 2-2a). Be sure to input the name of the veteran/patient and the veteran's/sponsor's SSN on the data entry screen. Generate a separate printout for each record being requested. On each printout the correspondence technician shall check the record being requested and write his/her name, office symbol, and date (see fig. 1-9.1). In addition, if there is more than one PRS printout, prepare NA Form 13105, NPRC Search Request and Reply. On the bottom of the left side of the form, the technician shall write in "See attached PRS printouts," his/her name, office symbol, and date. Staple all PRS printouts pertaining to one case to the NA Form 13105.

     d. All others.  For requests involving inpatient treatment prior to 1971 and all other requests for medical records to be searched by NRPMR-O, prepare NA Form 13105 indicating the records requested. Multiple requests can be listed using one NA Form 13105. (See fig. 1-9.2.)

     e. Information not furnished.  If the OR search information is not furnished by the requester, work the case to the extent possible and send a response to the requester using NA Form 13017, or appropriate response form and state, ASee attached NA Form 13042, Request for information Needed to Locate Medical Records. Attach NA Form 13042 and highlight areas of information needed for search. Also highlight the statement at the top of the form, "Please return this form and your original request."

10. Sending copies of medical records.  Each request is thoroughly examined to determine specifically what is needed. Reproduction of documents is held to an absolute minimum. Most inquiries for medical records are answered by furnishing photocopies of health records only, as distinct from clinical records (which require searching in organizational records). NA Form 13017 is generally used to transmit copies of health records and/or x-rays. The documents that are sent are listed in abbreviated form at the bottom of the file copy, which is retained in the record. The original is sent with the photocopied records.

11. Personal identifiers included on records.  Personal identifiers, such as social security number, of persons other than the individual whose records are involved, MUST be deleted whenever they are shown on health records before copies of these records are sent to the requester. For example, SF 88, Report of Medical Examination, may contain the social security number of the doctor and the home address of the veteran's next of kin.

12. Sending original medical records.

     a. VA Form 3101.  Original medical records are sent to VA Regional Offices (VARO's), but not to VA hospitals/medical centers. IF CLINICAL RECORDS ARE SENT, SEND THE JACKET AND ITS CONTENTS. The yellow VA envelope only needs to be used to enclose loose documents. Rubberband VA envelope with clinical records. Requests from VA hospitals/medical centers must come through a VARO. If an emergency request is received via FAX or telephone, then copies of medical records are sent.

     b. Reenlistment.  Original Navy, Marine Corps, and Coast Guard health records are sent to military activities upon request for reenlistment purposes.

     c. DD Forms 877.  Requests from military medical facilities for health/clinical records should be made on DD Form 877.

(1) Army and Air Force.  Regardless of the branch of service from which the request is received, send the original records. If requester has checked "Clinical," "Outpatient," and "Health," or "All available records" in item 8a, send all available records. (However, do not furnish original or photocopies of physical examination reports which are a part of the enlistment papers.) If only a certain portion of the record is specified, send only that portion.

     (a) Vital information not furnished.  If vital information to conduct clinical record search is not furnished, check item 12 and indicate information needed, or attach NA Form 13042 and highlight information needed to respond to request. Place check mark next to the address shown in item 19.

     (b) Records provided.  Check appropriate blocks in items 8b and 12. Show the registry file number in the upper right hand corner of the form. Enter in the remarks section, "Return records to address shown in item 4, Attn: (branch correspondence symbol)." Make sure NPRC address is clearly shown in item 4. Place check mark next to the address shown in item 19. Retain file copy in the record. For those responses that also include clinical records, DO NOT REMOVE CLINICAL RECORDS FROM THE JACKET. SEND JACKET AND ITS CONTENTS.

(2) Navy, Marine Corps, and Coast Guard.  If the request is from an Army or Air Force medical facility, send photocopies of the health record. Otherwise, send original health records and follow instructions in subpar. c(1), above.

NOTE: DD Forms 877 received from sources other than military medical facilities should be returned for resubmission on an appropriate form; e.g., SF 180. For additional information regarding records created by military medical facilities, see NPRC 1865.121.

13. Health records located at VA, RMC.  A Department of Veterans Affairs (VA) facility called the Service Medical Records Center (SMRC) opened in late 1992. Since then, the facility has been renamed the Records Management Center (RMC). All of the military service departments, except the Coast Guard, now send most individual health records to the RMC as soon as the service member's active duty or completion of service obligation has concluded, either by release, retirement, or discharge. These records are both stored and serviced at the RMC.

     a. Effective dates.  The service departments began to send health records to the RMC for persons released, retired, or discharged on or after the following dates:

(1) Army - October 16, 1992;

(2) Air Force and Marine Corps - May 1, 1994; and

(3) Navy - January 31, 1994. EXCEPTION: See par. 15, below;

(4) Coast Guard - April 1, 1998.

     c. Record indicates ARP, AFP, NVP, or MCP service code.

(1) Both personnel and health records are requested.  Check the inquiry for annotation made by the mailroom indicating that a copy of the request was sent to RMC.  If not found, photocopy the request and send the copy to the RMC using NA Form 13051, Transmittal. Prepare response to personnel records portion of request and use NA Form 13060, Referral, as the transmittal. Check mark appropriate blocks including the block advising requester of the referral to the RMC for health records.

(2) Health records only requested.  In most instances, mail analysts will identify these upon initial receipt and refer them to the RMC. However, for those requests that are overlooked by the mailroom, technicians should refer the original inquiry to the RMC using NA Form 13051. Send NA Form 13060 to the requester checking appropriate block.

(1) Both personnel and health records are requested.  If the last date of active duty as shown in the personnel record was on or after the service department began to send health records to the RMC, follow instructions in subpar. 13c(1), above.

(2) Health records only are requested.  If the last date of active duty as shown in the personnel record was on or after the service department began to send health records to the RMC, follow instructions in subpar. 13c(2), above.

     a. Date of discharge/retirement or other type of separation before 1-31-94.  The medical record is not at RMC. Probe the Registry file to ensure there is not a separate medical record at NPRC.  If the probe is negative, complete NA Form 13008, Loan or Transfer of Records, by placing an "X" in the box above the remarks section and write "PERS-313E, Rm. 5409." Write "No Health Record" in the remarks section. Forward the record along with the top copy of NA Form 13008 and the request to the BuMed Liaison Office, PERS-313E. Inform the requester of the referral using NA Form 13060. (Follow this procedure for VA 3101 requests also.)

     b. Date of discharge/retirement or other type of separation is on or after 1-31-94.  Refer the request to the VA, RMC, using NA Form 13051. Inform the requester of the referral using NA Form 13060.

15. Other Navy records erroneously retired to NPRC.  During March 1995 through February 1997, thousands of health records were received from the Naval Reserve Personnel Center (NRPC), New Orleans, LA, instead of being retired to the VA, RMC. These jackets have an "NM" service code.

1. General.  Navy health records for veterans discharged on or before June 30, 1976, are retired and maintained separately from service records. Navy medical records for personnel discharged on or after July 1, 1976, are combined with service records and filed in one location with the exception of records received from the NRPC during March 1995 through February 1997. Marine Corps medical records are maintained separately from service records for veterans discharged on or before June 30, 1977. After that date Marine Corps medical records are combined with service records and filed in one location. (See app. 1-A for dates retired to VA, RMC.)

2. Missing or incomplete Navy/Marine Corps medical records.  The missing portion of an incomplete medical record usually consists of all or part of the field health record for one or more periods of active service.

     a. Definition.  An "incomplete medical record" is defined as one which does not contain a document specifically requested or one which does not contain the document(s) NORMALLY furnished in reply to a specific type of inquiry. On a request from an insurance firm for medical data needed in determining eligibility for insurance, NPRC normally furnishes only a copy of the final physical examination. On such a request, therefore, if the final physical is in the record it would be considered complete, no matter what else may be missing. Do not consider a record incomplete because it does not contain a dental record if you are answering a request for which dental records are not needed.

     b. Computer probes and review of microfiched records.  Before determining that medical records are incomplete, be sure the computer has been probed correctly, by all available identifiers. In addition, records containing microfiche should be examined closely. Personnel records on microfiche often contain copies of entry and separation physical examination reports.

3. Missing/incomplete medical records (separated before 1-1-64).  NPRC is responsible for answering inquiries pertaining to personnel separated from service before January 1, 1964. If all efforts to locate record fail, make negative reply. Separation from service is defined as:

Transfer to the Fleet Reserve; Retirement from active military service;
Retirement, death or discharge while in a temporary disability retired status;
Release from active duty and transfer to a reserve status;
Discharge or death while serving on active duty; and
Discharge or death while serving as a member of the naval
reserve other than the Fleet Reserve.

5. Can't finds.  Certain inquiries are forwarded from the mailroom directly to the attention of the Correspondence Section Chief, Navy Reference Branch. For example, when an inquiry has been sent to a service department activity such as Naval Reserve Personnel Center (NRPC), New Orleans, LA, but returned to NPRC as "not found," the inquiry is sent to NRPMN-C as a "can't find." The Section Chief then determines whether a verification search is appropriate. (See the latest revision of NPRC 1865.32, Verification, misplaced, and "can't find" records searching.) The Section Chief may determine that a verification search is not justified because there is no evidence that NPRC has ever received the record. These inquiries should be forwarded to the Navy Liaison Officer for disposition.

6. Records received from NRPC with no health records.  Some records received from the Naval Reserve Personnel Center (NRPC) contain personnel records but no health records. They contain instead a pink notice stating "NO HEALTH RECORD AVAILABLE." These records have been entered into the NPRC registry system under the code PM (combined Navy personnel and medical records). As a result, other activities having access to NPRC's registry system finding media have assumed that the health records are on file here. When a request for medical records is received and only this type of record is found,  forward the inquiry and record to the BuMed Liaison Officer using NA Form 13008.  Notify the requester of the referral using NA Form 13060.

7. Use of Navy/Marine Corps medical records to supply personnel information, and vice versa. This paragraph provides instructions for using medical records to supply certain information when the personnel records are not here or are inadequate, and vice versa. There is some duplication of information in personnel and medical records. If one set of records is absent, the alternative records may be used to prevent wasted effort in searching and undue delay in answering inquiries.

     a. Responsibilities.  GS-6 archives technicians are responsible for casework where personnel type information in Navy medical records, or Navy medical type information in Marine Corps or Navy personnel records, may be used to answer an inquiry. Advice may be sought from the liaison officers.

     b. Instructions.

(1) General.  The following general instructions are followed when information used in replying to inquiries is obtained from files other than those from which it is customarily furnished:
(a) Compare information given in request with information in records. If alike, chances are the information in the files is accurate.

     (b) If it appears the pertinent record is still held by the service department, the "alternate" record may be used to answer only the most routine cases, such as address or service number requests, and cases from the service department.

     (c) Follow the current requirements for routing specific types of replies to or through the appropriate liaison officer(s).

(2) Caution statement.  In no case should information from the "alternate" file be used to resolve items which the request itself indicates are already in dispute, or to respond to requests for information to be used in legal action. Extreme caution should be exercised in using the "alternate" records to respond to the following:

     (a) Requests made in connection with obtaining benefits, such as inquiries from the VA, Social Security Administration, and Bureau of Employees' Compensation, as well as those from state and local governments.

     (b) Requests for statements of service for longevity purposes, or any type of retirement purposes.

     (c) Requests for a separation date when the exact date is of vital importance.

     (d) Requests for information which makes character of separation a vital item.

NOTE:  In cases where date and/or character of separation cannot be resolved with certainty, photocopy relevant pages of the alternate record and create a "temporary jacket" with the photocopies. Loan the "temporary jacket" to the appropriate service department activity for reconstruction action using NA Form 13008. Explain in the remarks section the circumstances of the case. File a copy of the form in the alternate record and return it to file.

(3) Documenting and filing record of correspondence action taken.  In any case where information used in replying to an inquiry is obtained from files other than those from which like information customarily is furnished, a "provisional" folder should be established for file in the location where the records should have been filed, or will be filed if received. The "provisional" folder should be established and handled as follows:

(a) When filing in non-Registry files is appropriate.  Place in appropriate jacket a copy of request and reply, noted to indicate folder from which information needed to make reply was obtained. In addition, place a WANTED card in jacket, indicating that when "regular" record does arrive, it should be charged out and delivered to NRPMN-C with the "provisional" folder and the WANTED card. The section chief compares the reply made from the alternate record with information in the "regular" record, and if reply was in error, ensures that amended reply is sent. The"provisional" and "regular" records are then merged and filed.

     (b) When filing in Registry File is appropriate.  Subpar. (a), above, applies. In addition, clearly mark the folder "Marine Pers," "Navy Pers," or "Navy Med," as appropriate. Route the folder to the NRPMO-A for assignment of a Registry Number and for indexing and processing into the Registry File.

1. Coverage of this chapter.  This chapter covers the processing of requests from veterans for photocopies of medical records. It also covers requests from sources acting in behalf of the veteran, including next of kin, members of Congress, attorneys, or other personal representatives. These requests have many underlying reasons, the most prevalent being for use in connection with insurance and VA claims, prospective employment, medical treatment, eligibility for veterans preference, insurance applications, etc.

2. Requests from veteran.  Information from or copies of his/her medical records may be released to a veteran unless it appears that such release might prove detrimental to his/her physical or mental health. Examples of potentially detrimental information include:

     a. Diagnosis of a mental, psychoneurotic, or personality disorder, such as psychoneurosis, psychosis, or other related condition.

     b. Diagnosis or implications of sexual deviation.

     c. Any illness that carries a uniformly unfavorable prognosis.

3. Record DOES NOT contain potentially detrimental information.

     a. Nonspecific requests.  If veteran, or authorized requester (see app. 3-A), asks only for medical records, without giving purpose or indicating a specific illness, injury, or condition, furnish only a copy of the final physical (SF 88, see fig. 3-3.1). If the final physical is not on file, send copies of other appropriate documents that satisfy the request. If a second request is received, stating that veteran received the SF 88 but wants medical records, furnish photocopies of complete health record. (See par. 15 of this chapter if request is from a veteran who indicates an intention to use the photocopies to support a VA claim.)

     b. Specific requests.  Specific requests, indicating specific illness, disease, injury, condition, document, time period and/or place of treatment, or purpose, are answered with photocopies of relevant health records. This may include copies of the final physical, clinical record cover sheets, briefs, or narrative summaries which relate to the period of hospitalization or illness. (See figs. 3-3.2, 3-3.3, 3-3.4 and 3-3.5.) (NOTE: If the health record contains no records relating to the specific condition, it may be necessary to obtain and furnish photocopies of the clinical record(s) pertaining to the specific condition or period of hospitalization. See NPRC 1865.121.) These general guidelines should be observed in determining which medical documents need to be copied and which do not:

(1) Lab reports, x-ray reports, and authorization forms.  Unless specifically requested, lab reports, x-ray reports, and authorization forms are not photocopied.

(2) Records containing EKG's.  If the record contains EKG's stapled to a Standard Form 520, Electrocardiographic Record, which indicates "NORMAL," "WITHIN NORMAL LIMITS," or "WNL," do not remove the EKG's from the SF 520 for individual copying. Make the copy "as is," which means only those on top will show. Affix a remark somewhere in the blank space as follows, "FULL EKG TRACING NOT SHOWN, ADVISE IF NEEDED." (Furnish full EKG's only if specifically requested.)

5. Confidential information defined.  There are certain types of medical records considered to be confidential or sensitive in nature. These include:

     a. Drug/alcohol abuse patient treatment records.  Records maintained in connection with the treatment, rehabilitation, and training of drug/alcohol abuse.

     b. Family Advocacy Program (FAP) records.  Since 1989, the Department of the Air Force, and since 1992, the Department of the Navy retire Family Advocacy Program (FAP) records to NPRC as separate systems of records. Because of the sensitive nature of these records, both the Air Force and the Navy require that the Center exercise special precautions before release to the veteran or any other requester. See par. 11 and par. 12 and the latest revision of NPRC 1865.16, apps. C-5 and D-6, for routine uses of these records systems.

     c. AIDS and sickle cell prevention and treatment records.  The Department of the Air Force has also included records pertaining to AIDS and sickle cell prevention and treatment records as confidential. The same release policies should be applied to these records as provided for drug abuse patient treatment records.

6. Confidentiality of drug abuse patient treatment records.  Section 408 of the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255) deals with the confidentiality of records maintained in connection with the treatment, rehabilitation, and training of drug/alcohol abuse patients. The Act imposes far greater restrictions on disclosure from these records than are applicable generally to medical records.

7. Drug/alcohol abuse patient records defined.  The records covered by the Act are those records maintained over any period of time, including those maintained before the enactment of the law, as long as treatment, rehabilitation, and training did not end before March 21, 1972, for drug abuse patients and May 14, 1974, for alcohol abuse patients. It is not necessary for the service person to have successfully completed the rehabilitation program; the records are still subject to the provisions of the Act. Identifying information is not restricted to medical treatment records, as long as whatever records involved were maintained in connection with the treatment, rehabilitation, and training of drug/alcohol abuse patients.

8. Screening records for rehabilitation documents.

     a. Documents/forms used.  During the years since March 1972 rehabilitation papers have been retired in the personnel and health portions of Marine Corps, Navy, Air Force, and Army records. To a lesser extent, they have also appeared in Coast Guard records. Therefore, it is necessary to screen the records retired by all military branches for this type of information. The rehabilitation records frequently appear with the administrative discharge papers or with the health records on Standard Form 502, Clinical Record Narrative Summary. Specific records pertaining to treatment and rehabilitation, filed in the health records, could be:

(1) DA Form 2985-1R, Alcohol and Drug Abuse Control Program Admission Information;

(2) DA Form 2985-2R, Individual Patient Data System Alcohol and Drug Abuse Control Program Intake Record;

(3) DA Form 2985-3R, Individual Patient Data System Alcohol and Drug Abuse Control Program Follow-up Record; and

(4) DA Form 4465, ADAPCP Military Client Intake and Follow-up Record (replaces above forms).

9. Exception to screening records.  NPRC is NOT required to screen medical records for collateral and incidental entries of drug and alcohol abuse information when the records are requested for official use by Federal government routine uses, when the veteran requests his/her own records, when a third-party requester provides an authorization signed by the veteran which specifically relates to these records, or in response to an Order of a Court of Competent Jurisdiction.

10. Unauthorized disclosure.  Although this instruction reduces to some extent the degree of screening required under the Drug Abuse Act, everyone should be aware of the seriousness with which unauthorized disclosure is regarded. Sec. 1401.51 of the covering regulation (21 CFR) reads as follows:

1401.51 Penalty for unauthorized disclosure. Subsection (e) of section 408 of the Act (21 U.S.C. 1175) provides that except as authorized under subsection (b) of that section, any person who discloses the contents of any record referred to in subsection (a) of that section shall be fined not more than $500 in the case of a first offense, and not more than $5,000 in the case of a second offense.

     a. Description.  FAP records include the medical records of suspected and confirmed cases of family abuse or neglect, investigative reports, correspondence, family advocacy committee reports, follow-up and evaluative reports, and any other supportive documentation. These records should NOT be filed in the military personnel or medical record of any veteran, although references or referrals may be noted. These incidental or collateral entries are not to be considered FAP records. Prior to 1989, the Air Force retired these types of records to CPR as Child Advocacy Records. Beginning in 1989, the Air Force determined that the records pertain to the family as a whole, and began to retire them to MPR under the veteran's name and social security number.

     b. Location.  The Air Force and Navy FAP records may be available through NRPMR-O. The FAP records of the Department of the Army are not retired to this Center. Any requests received which pertain to Army FAP records should be referred to: Brooke Army Medical Center, ATTN: Legal Section, Patient Administration Division, Building 1028, Fort Sam Houston, TX 78234-6200.

12. Record contains confidential information.  The procedures outlined in app. 3-C should be followed in working cases involving the types of confidential medical records described above.

13. Requests for certified copies.  This paragraph does NOT apply to legal demands (court order/subpoenas signed by a judge) for the production of authenticated copies of records. (See the latest revision of NPRC 1864.107 for procedures in processing legal demands.) However, a court order or subpoena is not required in order for the veteran or his/her authorized representative to obtain certified copies.

     a. Veteran for personal use.  If the veteran requests certified copies for personal use, send photocopies with the NARA seal imprint.

     b. For court proceedings.  If the requester is authorized access to the records, and requests certified copies to be used in court proceedings, then furnish certified copies according to the procedures that follow. Review the records and delete any third-party personal information. If information is deleted, include the following statement in the reply:

Information of a personal nature which relates to third persons and which appears

in the records requested has been deleted from the attached reproductions

pursuant to the Freedom of Information Act, 5 U.S.C. 552(b)(6), the Privacy Act of

1974, 5 U.S.C. 552a, and the regulations of the agency that created the

documents.  If you need reproductions without deletions, you must submit a valid

court order.  The attached notice provides information about this requirement.

Reproductions produced pursuant to a court order will be certified under the seal

of the National Archives and Records Administration.

14. Requests for x-rays.

     a. X-ray in record or located at CPR.  X-rays are not furnished to the veteran. Instead, they may be sent to the veteran's physician for interpretation. If the x-ray that is requested is found in the health jacket, or the x-ray is likely to be at CPR (i.e., it was taken at entrance or separation), advise the requester that the x-ray(s) must be sent to a physician to be interpreted and explained for the requester. Send NA Form 13017, checking the appropriate blocks. If the x-ray sought is supposed to be at CPR, circle the CPR address at the bottom of the form, along with checking the MPR address in the usual manner. NA Form 13017 is also used to transmit the x-ray(s) to the physician who is authorized to receive it (them). The transmittal block in the middle of the form is checked and the name of the person who submitted the request and provided the physician's name is printed in the blank space.

NOTE: An entrance or separation x-ray taken at a Navy facility between 1940 and 1969 cannot be located at CPR without the film number, day, month, and year the x-ray was taken, and the place where it was taken. This information is available on the SF 88 in the health jacket and must be written at the bottom of the NA Form 13017 sent to the requester when such an x-ray is requested.

     b. X-ray destroyed or not available.  If the x-ray has been destroyed, check the appropriate block on NA Form 13017 and furnish a copy of report of x-ray, if available. When the requester must be advised that interim x-rays are not available, NA Form 13017 is also used, by checking the block that describes the five-year retention period.

NOTE: If a facility has been closed within the past five years, the x-rays that are less than five years old are likely to have been sent to CPR.

     c. X-ray requested for identification purposes.  Requests for x-rays (especially dental x-rays) may occasionally be received from law enforcement activities for the purpose of identifying a body. X-rays may be loaned for this purpose within the boundaries of NPRC release policy. Check the first block of NA Form 13017. Also check the block that ends with "...MUST BE RETURNED TO THIS CENTER," crossing out all but that last sentence.

15. Request for records to support VA claims when medical records are on file at NPRC.  Copies are not usually provided to answer requests to support VA claims. Instead NA Form 13060 is used to suggest that the requester contact the VA, since it is VA policy to request from NPRC any records that will be needed to adjudicate a VA claim. Exceptions are made when there are other unusual circumstances. For example, the records may be needed in order to furnish copies under authentication certificate; or a member of Congress may ask that medical records be sent to a specific VARO. When replying for a member of Congress, send a copy of the Congressional inquiry to the VA (with enclosures) and always retain a copy for file.

16.Requested medical records on file at the VA.  Use NA Form 13060, appropriately marked, to inform the requester that records were lent to the VA. Include the VA claim number, if known, but only if the form is being sent to a veteran, the veteran's representative, or the next of kin.

17. Requesting return of records from the VA.  When it is appropriate to recall the records from the VA (generally, if the requester has had difficulty getting copies from that agency), prepare NA Form 13042B, Request for Medical/Dental Records and Other Information, in triplicate. Forward two copies to the VA office to which the last report was furnished. File third copy in a suspense file. Send a tracer if the requested records are not received from the VA within two weeks. Medical records are not returned to the VA unless their return has been requested on NA Form 13042B.

NOTE: NRPMR see NPRC 1865.112, fig. 2-5.2, parts 3 and 4.

18. Requests concerning occupational radiation exposure.  DD Form 1141, Record of Exposure to Occupational Ionizing Radiation, reports the amount of radiation to which an individual was exposed while on the job, such as while working on a nuclear- powered ship, and is a permanent part of the health record. In response to an inquiry regarding exposure to occupational radiation while in the military service, photocopy DD Form 1141 or other document(s) reporting radiation exposure, and send to the requester using NA Form 13017 as the transmittal with a copy for the record. If there is no DD Form 1141, or comparable source of information in the health record, take one of the following appropriate actions. Notify the requester on NA Form 13053 if the inquiry is referred to another office for reply.

     a. Army (non-fire-related), Navy, Marine Corps, and Coast Guard.

(1) Medical records loaned to VA.  If the record indicates the medical records were loaned to the VA, refer the requester to the VA using NA Form 13060. EXCEPTION: Do NOT refer requester to the VA if it is clear that the only record(s) lent would be of no value in this case, such as just the entrance physical.

(2) Medical records not found and not loaned to VA.  For Army (non-fire related) and Coast Guard records, send a negative reply. For Navy and Marine Corps records, forward the request to:

Naval Dosimetry Center
National Naval Medical Center
Code 42
Bethesda, MD 20814-5000

     c. Air Force records (including fire-related).  Forward the request, using NA Form 13051, to OEHL/RZ, Brooks AFB, TX 78235-5501. If the record shows that the medical records were loaned to the VA, refer the requester to the VA using NA Form 13060. NOTE: Do NOT refer requester to the VA if it is clear that the only record(s) lent would be of no value in this case, such as just the entrance physical.

19. Requests concerning radiation exposure as a result of atomic testing (includes fire-related requests).  Requests for information regarding radiation exposure as a result of atmospheric nuclear tests from 1945 to 1962 and in the occupation of Hiroshima or Nagasaki should be referred to:

Director, Defense Special Weapons Agency
ATTN: ESN (NTPR Program)
6801 Telegraph Rd.
Alexandria, VA 22310-3398
Phone: 1-800-462-3683

     a. Evidence found.  Write the paragraph below, inserting the word "gas" or "chemicals" depending on the situation:

A review of your records produced the enclosed documents regarding exposure to toxic __________. No other entries were found.

A review of your records failed to produce any entry regarding exposure to toxic ___________.

Naval Research Laboratory
Attn: Code 1230
4555 Overlook Ave., SW
Washington, DC 20375-5322