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VA Form 21-4142A Printable, Fillable in PDF – It is necessary to complete VA Form 21-4142A, General Release for Medical Provider Information to the Department of Veterans Affairs, in order for the Department of Veterans Affairs to get information on a Veteran’s private medical providers on his or her behalf (VA). A copy of the release is supplied with the accompanying supporting documentation:
- Form 21-526, Veterans Application for Compensation and/or Pension, is available from the Department of Veterans Affairs.
- Form 21-526B, Veteran’s Supplemental Claim for Compensation, is available from the VA.
- VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs, is used to request information from the VA.
- The most recent version of the form was made available to the public on March 1, 2018. A fillable VA Form 21-4142A is available for digital filing and may be downloaded from the link below, or it can be obtained on the Veterans Affairs Forms website.
The VA Form 21-4142A Must Be Completed In Its Entirety
The VA Form 21-4142A, Authorization to Disclose Information to the Department of Veterans Affairs, is given as part of the primary VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs, but it may also be downloaded and submitted alone.
The form is supplied without any indication on how it should be filled. Instructions for completing VA Form 21-4142A are provided below in step-by-step format.
- Veteran identification information is required under Section I (“Veteran’s Identification Information”) and includes the veteran’s name, Social Security Number (SSN), VA file number, service number, and birth date.
- It is necessary to provide Section II (“Patient Identification for Records the VA Requests”) in the event that the records are sought for someone other than the veteran.
- Information on the healthcare provider or medical facility is provided in Section III (“Medical Provider Information”), which also includes the dates of treatment.
- If the veteran has the capacity to collect the documents and physically present them to the VA, there is no need to fill out the form on the VA’s website. The submission of the VA Form 21-4142A will increase the amount of time it takes for your claim to be processed.