VA Form 21-4142A General Release for Medical Provider Information to the Department of Veteran Affairs (VA)

VA Form 21-4142A is a U.S. Department of Veterans Affairs form also known as the "General Release For Medical Provider Information To The Department Of Veteran Affairs (va)". The latest edition of the form was released in March 1, 2018 and is available for digital filing.

Download a PDF version of the VA Form 21-4142A down below or find it on U.S. Department of Veterans Affairs Forms website.

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OMB Control No. 2900-0858
Respondent Burden: 5 minutes
Expiration Date: 03/31/2021
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION
TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
INSTRUCTIONS - COMPLETE AND ATTACH THIS FORM WITH A SIGNED VA FORM 21-4142,
AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS
(VA). IF YOU HAVE MORE THAN FIVE PROVIDERS, FILL OUT ADDITIONAL COPIES OF THIS
FORM, AVAILABLE AT WWW.VA.GOV/VAFORMS.
NOTE - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BELOW BEFORE COMPLETING THIS FORM.
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
4. DATE OF BIRTH (MM/DD/YYYY)
2. SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. VETERAN'S SERVICE NUMBER (If applicable)
SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)
6. PATIENT'S NAME (First, Middle Initial, Last)
7. SOCIAL SECURITY NUMBER
8. VA FILE NUMBER (If applicable)
SECTION III - MEDICAL PROVIDER INFORMATION
9B. DATE(S) OF TREATMENT:
9A. PROVIDER OR FACILITY NAME
(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 9A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
9C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
10B. DATE(S) OF TREATMENT:
10A. PROVIDER OR FACILITY NAME
(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 10A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
10C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
VA FORM
PAGE 1
21-4142a
MAR 2018
OMB Control No. 2900-0858
Respondent Burden: 5 minutes
Expiration Date: 03/31/2021
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION
TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
INSTRUCTIONS - COMPLETE AND ATTACH THIS FORM WITH A SIGNED VA FORM 21-4142,
AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS
(VA). IF YOU HAVE MORE THAN FIVE PROVIDERS, FILL OUT ADDITIONAL COPIES OF THIS
FORM, AVAILABLE AT WWW.VA.GOV/VAFORMS.
NOTE - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BELOW BEFORE COMPLETING THIS FORM.
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
4. DATE OF BIRTH (MM/DD/YYYY)
2. SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
4. VETERAN'S SERVICE NUMBER (If applicable)
SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)
6. PATIENT'S NAME (First, Middle Initial, Last)
7. SOCIAL SECURITY NUMBER
8. VA FILE NUMBER (If applicable)
SECTION III - MEDICAL PROVIDER INFORMATION
9B. DATE(S) OF TREATMENT:
9A. PROVIDER OR FACILITY NAME
(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 9A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
9C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
10B. DATE(S) OF TREATMENT:
10A. PROVIDER OR FACILITY NAME
(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 10A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
10C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
VA FORM
PAGE 1
21-4142a
MAR 2018
VETERAN'S SOCIAL SECURITY NO.
11B. DATE(S) OF TREATMENT:
11A. PROVIDER OR FACILITY NAME
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 11A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
11C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
12B. DATE(S) OF TREATMENT:
12A. PROVIDER OR FACILITY NAME
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 11A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
12C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
Country
State/Province
ZIP Code/Postal Code
13B. DATE(S) OF TREATMENT:
13A. PROVIDER OR FACILITY NAME
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 11A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
13C. PROVIDER/FACILITY STREET ADDRESS
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of
1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research
studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and
delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation,
Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.
However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the health care provider to which this authorization is
addressed may not be able to identify and locate your records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help
ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will
not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by
Federal Statute of law in effect prior to January 1, 1975 and still in effect.
RESPONDENT BURDEN: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for this information. We estimate
that you will need an average of 5 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.reginfo.gov/public/do/PRAMain. If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-4142a, MAR 2018
PAGE 2

Download VA Form 21-4142A General Release for Medical Provider Information to the Department of Veteran Affairs (VA)

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