Fillable Form VA 21-4142 (2018)

What is VA Form 21-4142?

The Authorization to Disclose Information to the Department of Veterans Affairs (VA) also known as the VA Form 21-4142 is used by the Department of Veterans Affairs. This gives them permission to obtain your personal information from a non-VA source like a private doctor or hospital.

The information gathered will help determine your eligibility for VA benefits. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care. By signing VA Form 21-4142, you authorize any doctors, hospitals, or caregivers that have treated you to release information about your treatment to the VA.

VA Form 21-4142 is used with VA Form 21-526 - Application for Compensation & Pension.

What do I use VA Form 21-526 for?

Use VA Form 21-526 to apply for compensation and/or pension benefits.

You should apply for compensation benefits if any of the following are true:

• You were injured while you were in the service.
• You were seriously ill while you were in the service, and you believe you have continuing problems.
• You developed a mental or physical condition that may be related to your military service.
• You are permanently and totally disabled, and you believe it is because of your military service.

You should apply for pension benefits if all of the following are true:

• You are permanently and totally disabled (but not as a result of your military service).
• You served on active duty during a wartime period.
• Your income is limited.

VA pays disability pension to veterans who:

• are permanently and totally disabled but not as a result of military service or the veteran's own willful misconduct
• served during:
  • Mexican Border Period
  • World War I
  • World War II
  • Korean Conflict
  • Vietnam Era
  • Gulf War

How to fill out VA Form 21-4142?

Before filling out the form, make sure that the information given is correct. Write as legible as possible to avoid errors and the possible need for corrections.

• Records to be released to the Department of Veterans Affairs (VA)
  • Statement that veteran is authorizing the release of all information regarding treatment, hospitalization, and outpatient care for impairment(s) including:
    • psychological, psychiatric, or other mental impairment note
    • drug abuse, alcoholism, or other substance abuse
    • sickle cell anemia
    • records which may indicate the presence of a communicable or non-communicable disease, and tests for or records of HIV/AIDS
    • gene-related impairments;
  • information about how impairment(s) affects my ability to complete tasks and activities of daily living and effects on ability to work
  • information created within 12 months after the date the authorization is signed

Provide the following information:

Section 1

• Veteran Identification Information
  • Veteran/beneficiary’s name
    • (First, Middle Initial, Last)
  • Social security number
  • VA file number
  • Date of birth
    • (MM/DD/YYYY)
  • Veteran’s service number
    • (If applicable)
  • Mailing address
    • (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
  • Email address
    • (Optional)
  • Telephone
    • (Include Area Code)

Section 2

• Patient Identification for Records VA is Requesting (If other than veteran)
  • Patient’s name
    • (First, Middle Initial, Last)
  • Social security number
  • VA file number
    • (If applicable)

Section 3

• Information Regarding Source of Record(s)
  • Indication that records may come from all medical sources (including mental health, correctional, addiction treatment, and VA health care facilities), social workers/rehabilitation counselors, consulting examiners, employers, insurance companies, workers’ compensation programs, and others who may know about condition

Section 4

• Records to be Released to the Department of Veteran Affairs

Section 5

• Authorization and Consent to Release Information to VA and Signature
• Any limitation on the consent
  • Signature of person authorizing disclosure
  • Date signed
  • Printed name of person signing
  • Relationship to veteran/claimant

General Release for Medical Provider Information to Department of Veterans Affairs (VA)

Section 1

• • Veterans identification information
    • Veteran’s name
      • (First, Middle Initial, Last)
    • Social security number
    • VA file number
    • Date of birth
      • (MM/DD/YYYY)
    • Veteran’s service number
      • (If applicable)

Section 2

• • Patient identification for records VA is requesting (If other than veteran)
    • Patient’s name
      • (First, Middle Initial, Last)
    • Social security number
    • VA file number

Section 3

• • Medical provider information
    • Provider or facility name
    • Dates of treatment
      • (Include the time period (MM-DD-YYYY) for the treatment by the provider)
    • Provider/facility street address
      • (Number and street, P.O. or rural route)

Where to file VA Form 21-4142?

• • It is important that you keep a copy of all the forms you fill out and give to VA. This way you will have your own complete record to refer to.
  • Be sure to sign and date the form.
  • Make as many copies of VA Form 21-4142 as you need to give authorization to all the doctors, medical facilities, or caregivers that treated you.
  • Make a photocopy of your application and everything that you submit to VA. By having copies, you will be prepared if VA has a question about your application.
  • Mail the original application and your supporting materials to the closest VA office. You can find the address in your local telephone book or at the VBA internet web site: www.va.gov
  • If you find that you need to change or add information to your application, contact VA where you submitted your application immediately. In a letter, make sure you specify:
    • your name,
    • claim number if you know it (or Social Security number if you don't know the claim number), and
    • the item number you want to change or add to

What can I do to help get my application processed faster?

VA will make reasonable efforts to help you get this evidence. You can help by telling VA about all the evidence that supports your claim. Evidence is information that confirms that what you are telling VA is correct. For instance, if you are claiming service connection for a certain disability, they will help you by requesting medical records from your doctor or from the VA that show you have this disability. They will also help you by requesting records from other Federal or non-Federal agencies or companies. They will request your service medical records in claims for compensation.