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DD FORM 877 SEP 67 REPLACES EDITION OF 1 JAN. 60. WHICH MAY BE USED. Reset USAPPC V1. 00 Adobe Professional 7. REQUEST FOR MEDICAL/DENTAL RECORDS OR INFORMATION REQUESTING ACTIVITY -Complete Items 1 through 10 Except 8b also ADDRESSEE DATE complete Item 19. - Complete Items 8b 11 to 14 or 15 to 18 as appropriate final referrer shall return to requester. 1. PATIENT Last Name - First Name - Middle Name 3. STATUS MILITARY VA BENEFICIARY FEDERAL EMPLOYEE DEPENDENT 2. ORGANIZATION AND PLACE OF TREATMENT OTHER Specify 3a* NAME OF SPONSOR If dependent 4. TO Include ZIP Code IDENTIFYING INFORMATION a* SERVICE NUMBER b. GRADE/RATE c* SOCIAL SECURITY ACCOUNT NO. d. VA CLAIM NUMBER e. DATE OF BIRTH If Federal employee 6. DATES OF TREATMENT Inclusive a* RECORDS REQUESTED MIL VA 7. DISEASE OR INJURY b. RECORDS FORWARDED MIL VA 9. REMARKS CLINICAL OUTPATIENT HEALTH RECORD DENTAL RECORD X-RAY MEDICAL REPORT CARDS EMERGENCY MEDICAL TAGS FIELD MEDICAL CARDS ABSTRACT OF RATING SHEET REPORT OF PHYSICAL EXAMINATION ALL AVAILABLE RECORDS Except X-rays unless specifically requested 10. SIGNATURE OTHERS List under remarks REPLY/REFERRAL 11. TO RECORDS CHECKED IN 8b FORWARDED. NO RECORDS FOUND FOR PATIENT DURING ABOVE PERIOD. 14. DATE REPLY/SECOND REFERRAL 15. TO 19. RETURN TO Include ZIP Code ENTER COMPLETE ADDRESS TO WHICH RECORDS OR FINAL REPLY SHOULD BE MAILED. REQUEST FOR MEDICAL/DENTAL RECORDS OR INFORMATION REQUESTING ACTIVITY -Complete Items 1 through 10 Except 8b also ADDRESSEE DATE complete Item 19. - Complete Items 8b 11 to 14 or 15 to 18 as appropriate final referrer shall return to requester. 1. - Complete Items 8b 11 to 14 or 15 to 18 as appropriate final referrer shall return to requester. 1. PATIENT Last Name - First Name - Middle Name 3. STATUS MILITARY VA BENEFICIARY FEDERAL EMPLOYEE DEPENDENT 2. PATIENT Last Name - First Name - Middle Name 3. STATUS MILITARY VA BENEFICIARY FEDERAL EMPLOYEE DEPENDENT 2. ORGANIZATION AND PLACE OF TREATMENT OTHER Specify 3a* NAME OF SPONSOR If dependent 4. TO Include ZIP Code IDENTIFYING INFORMATION a* SERVICE NUMBER b. ORGANIZATION AND PLACE OF TREATMENT OTHER Specify 3a* NAME OF SPONSOR If dependent 4. TO Include ZIP Code IDENTIFYING INFORMATION a* SERVICE NUMBER b. GRADE/RATE c* SOCIAL SECURITY ACCOUNT NO. d. VA CLAIM NUMBER e. DATE OF BIRTH If Federal employee 6. GRADE/RATE c* SOCIAL SECURITY ACCOUNT NO. d. VA CLAIM NUMBER e. DATE OF BIRTH If Federal employee 6. DATES OF TREATMENT Inclusive a* RECORDS REQUESTED MIL VA 7. DISEASE OR INJURY b. RECORDS FORWARDED MIL VA 9. DATES OF TREATMENT Inclusive a* RECORDS REQUESTED MIL VA 7. DISEASE OR INJURY b. RECORDS FORWARDED MIL VA 9. REMARKS CLINICAL OUTPATIENT HEALTH RECORD DENTAL RECORD X-RAY MEDICAL REPORT CARDS EMERGENCY MEDICAL TAGS FIELD MEDICAL CARDS ABSTRACT OF RATING SHEET REPORT OF PHYSICAL EXAMINATION ALL AVAILABLE RECORDS Except X-rays unless specifically requested 10. REMARKS CLINICAL OUTPATIENT HEALTH RECORD DENTAL RECORD X-RAY MEDICAL REPORT CARDS EMERGENCY MEDICAL TAGS FIELD MEDICAL CARDS ABSTRACT OF RATING SHEET REPORT OF PHYSICAL EXAMINATION ALL AVAILABLE RECORDS Except X-rays unless specifically requested 10. SIGNATURE OTHERS List under remarks REPLY/REFERRAL 11. TO RECORDS CHECKED IN 8b FORWARDED. NO RECORDS FOUND FOR PATIENT DURING ABOVE PERIOD.

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