VA Form 21-4142a General Release for Medical Provider Information to The

OMB Control No. 2900-0858
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

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 ON
PAGE 2 BEFORE COMPLETING THIS FORM.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH

3. VA FILE NUMBER

Month

Day

Year

5. 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)
8. VA FILE NUMBER

7. SOCIAL SECURITY NUMBER

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:
9C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code
10B. DATE(S) OF TREATMENT:

(Include the time period (MM-DD-YYYY)
for the treatment by the provider listed in Item 10A)

10A. PROVIDER OR FACILITY NAME

From:

To:
10C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
No. &
Street
City

Apt./Unit Number
State/Province
VA FORM
XXX XXXX

21-4142a

Country

ZIP Code/Postal Code

SUPERSEDES VA FORM 21-4142a, MAR 2018.

PAGE 1

VETERAN'S SOCIAL SECURITY NO.
11B. DATE(S) OF TREATMENT:

(Include the time period (MMDDYY)
for the treatment by the provider listed in Item 11A)

11A. PROVIDER OR FACILITY NAME

From:

To:
11C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code
12B. DATE(S) OF TREATMENT:

(Include the time period (MMDDYY)
for the treatment by the provider listed in Item 12A)

12A. PROVIDER OR FACILITY NAME

From:

To:
12C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
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 13A)
From:

To:
13C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
No. &
Street
Apt./Unit Number
State/Province

City
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, 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.
PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact
knowing it to be false.
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, XXX XXXX

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