About VA Form 21-4142a
- Form name: General Release for Medical Provider Information to the Department of Veterans Affairs
- Related to: Disability, Health care
- Form last updated: June 2022
When to use this form
Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
Downloadable PDF
Online tool
You can submit your authorization online instead of sending us the paper form.
Go to the online toolRelated forms and instructions
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VA Form 21-4142
Form name: Authorization to Disclose Information to the Department of Veterans Affairs (VA)
Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.
Download VA Form 21-4142 (PDF)
Helpful links related to VA Form 21-4142a
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Securely review, download, and share your medical records.
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Find out if you qualify for compensation for a presumptive disability or other service-connected conditions.
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Find out how to file a claim for disability compensation or increased disability compensation.