Form 21-4142 Authorization to Disclose Information to VA

OMB Control No. 2900-0858
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

AUTHORIZATION TO DISCLOSE INFORMATION TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this
form to provide your written authorization to obtain your treatment records, so the VA can get the information required
to process your claim. For more information, you can contact us online through Ask VA: https://ask.va.gov/ or call us
toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. For mailing information see
page 3.

SECTION I - VETERAN IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, and insert one letter per
box, to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)
3. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable)

6. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

7. TELEPHONE NUMBER (Include Area Code)

ZIP Code/Postal Code
8. E-MAIL ADDRESS (Optional)

I agree to receive electronic correspondence
from VA in regards to my claim.

Enter International Phone Number (If applicable)

SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)

9. PATIENT'S NAME (First, Middle Initial, Last)

10. SOCIAL SECURITY NUMBER

SOURCE OF RECORD(S):

11. VA FILE NUMBER (If applicable)

SECTION III - INFORMATION REGARDING SOURCE OF RECORD(S)

• ALL medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment,
and VA health care facilities,
• Social workers/rehabilitation counselors,
• Consulting examiners used by VA,
• Employers, insurance companies, workers' compensation programs, and
• Others who may know about my condition (family, neighbors, friends, public officials).

SECTION IV - RECORDS TO BE RELEASED TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of: All my medical records; including information related to my
ability to perform tasks of daily living. This includes specific permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, but not limited to:
a. Psychological, psychiatric, or other mental impairment(s) excluding "psychotherapy notes" as defined in 45 C.F.R. §164.501,
b. Drug abuse, alcoholism, or other substance abuse,
c. Sickle cell anemia,
d. Records which may indicate the presence of a communicable or non-communicable disease; and tests for or records of
HIV/AIDS,
e. Gene-related impairments (including genetic test results)
2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
3. Information created within 12 months after the date this authorization is signed in Item 13, as well as past information.
YOU SHOULD NOT COMPLETE THIS FORM UNLESS YOU WANT THE VA TO OBTAIN PRIVATE TREATMENT RECORDS ON YOUR BEHALF. IF YOU
HAVE ALREADY PROVIDED THESE RECORDS OR INTEND TO OBTAIN THEM YOURSELF, THERE IS NO NEED TO FILL OUT THIS FORM. DOING SO WILL
LENGTHEN YOUR CLAIM PROCESSING TIME. THIS FORM IS NOT NEEDED TO REQUEST VA MEDICAL RECORDS.

IMPORTANT: In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees charged by a custodian to provide records requested."
VA FORM
XXX XXXX

21-4142

SUPERSEDES VA FORM 21-4142, JUL 2021.

Page 1

VETERAN'S SOCIAL SECURITY NO.

SECTION V- AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE
12. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):

TO WHOM: The Department of Veterans Affairs (VA).
PURPOSE: Determining my eligibility for benefits, and whether I can manage such benefits.
EXPIRES: This authorization is good for 12 months from the date shown in Item 14.
• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above in Section I.
• I understand that there are some circumstances in which this information may be re-disclosed to other parties (See page 2 for details).
• I may write to VA and my source(s) to revoke this authorization at any time (See page 2 for details).
• VA will give me a copy of this form, if I ask; I may also ask the source(s) to allow me to inspect or get a copy of material to be disclosed.
• I have read both pages of this form and agree to the disclosures above from the types of sources listed. See Patient Acknowledgment
below.
13. SIGNATURE OF PERSON AUTHORIZING DISCLOSURE (Required)
14. DATE SIGNED (MM/DD/YYYY) (Required)

15. PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last)

16. RELATIONSHIP TO VETERAN/CLAIMANT (If other than self, please provide full name, title, organization, street, city, State, and ZIP code. All court

appointments must include docket number, county, and State)

NOTE: This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical and other information under
P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; 42 U.S.C. §290dd-2; 42 C.F.R. part 2, and State Law.
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of material fact
knowing it to be false.
If you do not revoke this authorization, it will automatically expire in 12 months from the date you sign and date the form. Signing this form is voluntary, but failing
to sign it, or revoking it before we receive necessary information could prevent an accurate or timely decision on your claim, and could result in denial or loss of
benefits. Although the information we obtain with this form is almost never used for any purpose other than those stated above, the information may be disclosed by
VA without your consent if authorized by Federal laws such as the Privacy Act.
Under the Government Paperwork Elimination Act (GPEA) (Public Law 105-277), the Office of Management and Budget (OMB) ensures that agencies, when
practicable, provide for the option of electronic maintenance, submission of disclosure of information and for the use and acceptance of electronic signatures. GPEA
states that electronic records submitted or maintained in accordance with the procedures developed by OMB, or electronic signature or other forms of electronic
authentication used in accordance with such procedures, "shall not be denied legal effect, validity, or enforceability merely because such records are in electronic
form" (Public Law 105-277, section 1707).
PATIENT ACKNOWLEDGMENT: I HEREBY AUTHORIZE the sources listed in Section IV, to release any information that may have been obtained in
connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will use this information in determining my
eligibility to veterans benefits I have claimed. I understand that the source being asked to provide the Veterans Benefits Administration with records under this
authorization may not require me to execute this authorization before it provides me with treatment, payment for health care, enrollment in a health plan, or
eligibility for benefits provided by it. I understand that once my source sends this information to VA under this authorization, the information will no longer be
protected by the HIPAA Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a, and VA may disclose this information as authorized by law. I
also understand that I may revoke this authorization in writing, at any time except to the extent a source of information has already relied on it to take an action. To
revoke, I must send a written statement to the VA Regional Office handling my claim or the Board of Veterans' Appeals (if my claim is related to an appeal) and
also send a copy directly to any of my sources that I no longer wish to disclose information about me. I understand that VA may use information disclosed prior to
revocation to decide my claim.
NOTE: For additional information regarding VA Form 21-4142, refer to the following website: https://www.benefits.va.gov/privateproviders/.
PRIVACY ACT INFORMATION: 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 Veteran Readiness 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 source 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 2900-0858, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5
minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA
Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0858 in any correspondence. Do not send your completed VA Form 21-4142 to
this email address.

VA FORM 21-4142, XXX XXXX

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WHERE TO SEND YOUR WRITTEN CORRESPONDENCE
Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA recommends submitting
correspondence electronically as this is the fastest method of receipt.
VA provides several tools to assist in electronic submission. To learn more about how to submit documents and claims electronically,
visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to access.va.gov to digitally upload any
correspondence using Direct Upload.
By visiting www.va.gov you can also check your claims status and learn about other VA benefits.
If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.
If you prefer to mail your correspondence, please use the related mailing address below.
COMPENSATION CLAIMS

PENSION & SURVIVORS BENEFIT CLAIMS

Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

FIDUCIARY

BOARD OF VETERANS' APPEALS

Department of Veterans Affairs
Fiduciary Intake
PO Box 95211
Lakeland, FL 33804-5211

Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038

These addresses serve all United States and foreign locations.

VA FORM 21-4142, XXX XXXX

Page 3

OMB Control No. 2900-0858
Respondent Burden: 5 minutes
Expiration Date: 07/31/2024

VA DATE STAMP
DO NOT WRITE IN THIS SPACE

GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION
TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page
2. Use this form to provide the name of the provider or facility you have received treatment from to the
VA. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number
is 711. VA forms are available at www.va.gov/vaforms. After completing the form, mail to: Department
of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, and insert one letter per
box, to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER

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)

7. SOCIAL SECURITY NUMBER

8. VA FILE NUMBER

SECTION III - MEDICAL PROVIDER INFORMATION
9C. DATE(S) OF TREATMENT:

9B. CONDITIONS YOU ARE BEING
TREATED FOR

9A. PROVIDER OR FACILITY NAME

(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 9A)
From:
To:

9D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

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

10B. CONDITIONS YOU ARE BEING
TREATED FOR

10A. PROVIDER OR FACILITY NAME

(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 10A)
From:
To:

10D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

VA FORM
XXX XXXX

21-4142a

City
Country

ZIP Code/Postal Code

SUPERSEDES VA FORM 21-4142a, JUL 2021.

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

11B. CONDITIONS YOU ARE BEING
TREATED FOR

11A. PROVIDER OR FACILITY NAME

(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 11A)
From:
To:

11D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

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

12B. CONDITIONS YOU ARE BEING
TREATED FOR

12A. PROVIDER OR FACILITY NAME

(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 12A)
From:
To:

12D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code
13C. DATE(S) OF TREATMENT:

13B. CONDITIONS YOU ARE BEING
TREATED FOR

13A. PROVIDER OR FACILITY NAME

(Include the time period (MM/DD/YYYY)
for the treatment by the provider listed in Item 13A)
From:
To:

13D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

PRIVACY ACT INFORMATION: 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 Veteran Readiness 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.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 2900-0858, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5
minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA
Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0858 in any correspondence. Do not send your completed VA Form 21-4142 to
this email address.

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.

VA FORM 21-4142a, XXX XXXX

Page 2