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

VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA. Without this information, determination of entitlement would not be possible. This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned. VA Forms 21-4142 and 21-4142a are being revised to include new standardization data points; to include optical character recognition boxes. VA Form 21-4142a has been further revised to include patient identification information. This addition does not increase the burden.

The latest form for Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a) expires 2021-03-31 and can be found here.