About VA Form 21-4142a
- Form name: General Release for Medical Provider Information to the Department of Veterans Affairs
- Related to: Disability, Health care
- Form revision date: August 2024
When to use this form
Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
Downloadable PDF
Online tool
You can submit your authorization online instead of sending us the paper form.
Related forms and instructions
VA Form 21-4142
Form name: Authorization to Disclose Information to the Department of Veterans Affairs (VA)
Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.
Helpful links related to VA Form 21-4142a
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Securely review, download, and share your medical records.
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Find out if you qualify for compensation for a presumptive disability or other service-connected conditions.
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Find out how to file a claim for disability compensation or increased disability compensation.