Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)

Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0858 can be found here:

Documents and Forms

Document Name Document Type
Form 21-4142 Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a) Form
21-4142 General Release for Medical Provider Information to the VAF 21-4142.pdf www.va.gov/vaforms/ Form
21-4142a General Release for Medical Provider Information to the VAF 21-4142a.pdf www.va.gov/vaforms/ Form

Information Collection (IC) Details

IC Title:	Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4142	General Release for Medical Provider Information to the VA	VAF 21-4142.pdf	https://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	21-4142a	General Release for Medical Provider Information to the VA	VAF 21-4142a.pdf	https://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 132,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	132,400	132,400
Annual IC Time Burden (Hours)	11,033	11,033
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.