VA Form 21-4142 Printable, Fillable in PDF

Table of Contents

VA Form 21-4142 Printable, Fillable in PDF – Also known as an Authorization and Consent to Release Information, is a document that is used by the Department of Veterans Affairs and is frequently referred to as such. Providing approval for the VA to access information about a veteran’s medical history and any treatments he or she may have had is required under this document. Using VA Form 21-4142 is a simple process that just requires the veteran’s name, social security number, and Veterans Administration file number. In addition, the veteran will be required to indicate the sources from which the VA may get essential information, as well as the dates on which medical treatments were received by the veteran and his or her family. Once this form has been completed and filed, the Department of Veterans Affairs (VA) may make a determination as to what benefits the veteran will be eligible for.

What Is A VA Form 21 4142 And How Does It Work?

The Department of Veterans Affairs and the Veterans Benefits Administration will utilize this form to process claims for veterans’ benefits. The VA Form 21-4142, also known as an Authorization and Consent to Release Information to the Department of Veterans Affairs, is used to authorize and consent to the release of information to the Department of Veterans Affairs (VA). The form must be completely filled out in order for the VA to get information about your medical treatments and past medical history from you. In order to establish your eligibility for VA benefits, you will need to provide the following information.

The form is quite straightforward to fill out and just takes a few pieces of basic information. It will be necessary for the filer to submit their identifying information, which will include their complete name, social security number, and VA file number. The claimant will next be required to provide a list of the sources from which the VA may get the necessary information. They may also provide specific dates for the treatments to make it simpler for others to discover the information.

The Most Frequently Encountered Applications

Veterinarians often utilize this form to permit their healthcare providers to disclose and release all of their medical data to the Veterans Administration.

A VA Form 21 4142 Consists Of The Following Components:

The following parts are included inside a VA Form 21-4142:

Department of Veterans Affairs will be given access to certain records (VA)
Information about the Veteran’s Identification
The VA is requesting patient identification information for records.
Information pertaining to the source of the record (s)
Signature on the Authorization and Consent to Release Information to the VA form.
Veterans Affairs (VA) Form 21-4142a – General Release for Medical Provider Information to the Department of Veterans Affairs (VA).

Detailed Instructions On How To Complete VA Form 21 4142

You must include the following information on VA Form 21-4142 in order to complete it properly:

Department of Veterans Affairs will be given access to certain records (VA)

A statement that the veteran authorizes the release of all information regarding treatment, hospitalization, and outpatient care for impairment(s), including but not limited to: psychological, psychiatric, or other mental impairment note; drug abuse, alcoholism, or other substance abuse; sickle cell anemia; records which may indicate the presence of a communicable or non-communicable disease, and tests for or records of HIV/AIDS; gene-related impairments; information about how impairment(s) a veteran has developed; and within 12 months after the signing of the authorization, information that has been produced

Veteran Identification Information

Veteran/beneficiary’s name (first, middle initial, last)
Social security number
VA file number
Date of birth
Veteran’s service number
Mailing address
Email address
Telephone

Patient Identification for Records VA is Requesting

Patient’s name
Social security number
VA file number

Information Regarding Source of Record

An indication that records may come from all medical sources (including mental health, correctional, addiction treatment, and VA health care facilities), social workers/rehabilitation counselors, consulting examiners, employers, insurance companies, workers’ compensation programs, and others who may know about the condition

Authorization and Consent to Release Information to VA and Signature

Any limitation on the consent

Signature of the person authorizing disclosure
Date signed
The printed name of the person signing
Relationship to veteran/claimant

General Release for Medical Provider Information to Department of Veterans Affairs (VA)

Veterans identification information
Social security number
VA file number
Date of birth
Veteran’s service number
Patient identification for records VA is requesting
Patient’s name
Social security number
VA file number
Medical provider information
Provider or facility name
Dates of treatment
Provider/facility street address

Notice Under The Privacy Act

This form is for routine uses only, as defined in the VA system of records, and will not be disclosed to any source other than those authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (for example, civil or criminal law enforcement, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, and the administration of VA programs and the delivery of VA benefits). Your claim file is identified by the VA using your Social Security number (SSN). In and of itself, refusing to submit your Social Security number will not result in the rejection of payments. In the event that a person refuses to submit his or her SSN, the VA will not deny him or her benefits unless such disclosure is required by a Federal Statute of law that was in force before January 1, 1975, and is still in effect today.

VA Form 21-4142 Printable, Fillable in PDF

Download VA Form 21-4142 [PDF]