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

Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)

Documents and Forms

Document Name Document Type
Form 21-4142 Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a) Form
21-4142 Authorization to Disclose Information to VA VA Form 21-4142 (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form
21-4142 Authorization to Disclose Information to VA VA Form 21-4142 (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form
21-4142a General Release of Medical Provider Information to VA VA Form 21-4142a (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form
21-4142a General Release of Medical Provider Information to VA VA Form 21-4142a (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 160 45 CFR 164 38 CFR 2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4142	Authorization to Disclose Information to VA	VA Form 21-4142 (OMB Exp. 7-31-24).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	21-4142a	General Release of Medical Provider Information to VA	VA Form 21-4142a (OMB Exp. 7-31-24).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: 58VA21/22/28, Compensation, Pension, Education, Veteran Readiness and Employment Records - VA	FR Citation: 87 FR 8740

Number of Respondents: 440,246	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	440,246	312,849	127,397
Annual IC Time Burden (Hours)	36,687	26,071	10,616
Annual IC Cost Burden (Dollars)	0	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.