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Get VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA). Use this form to give VA permission to obtain your personal information such as your medical treatment, hospitalizations, psychotherapy, or outpatient care.
Use this form to provide your written authorization to obtain your treatment records, so the VA can get the information required to process your claim. For more information, you can contact us online through Ask VA: https://ask.va.gov/ or call us toll-free at 1-800-827-1000 (TTY: 711).
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)
Use this form to provide the name of the provider or facility you have received treatment from to the VA. For more information, contact us at https://ask.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
Get VA Form 21-4142 to download. Submit a lay or witness statement to support a VA claim (VA Form 21-10210) When to use this form. Use this form to submit a formal statement to support your VA claim—or the claim of another Veteran or eligible family member. People also sometimes call this statement a “buddy statement.” How to submit this form.
If you received treatment at a military hospital or clinic after your discharge, please include facility information and the date ranges of your medical treatment records for your claimed conditions when completing VA Forms 21-4142 and 21-4142a.
The signed VA Form 21-4142 specifies that the authorization permits you to disclose all of your patient's medical or educational information to the Department of Veterans Affairs (VA) for the time period requested.
may 2004 21-4142 existing stocks of va form 21-4142, sep 2003, will be used. 1. last name - first name - middle name of veteran (type or print) 3. claimant's name (if other than veteran) last name, first, middle 5. relationship of claimant to veteran 7a. list the name and address of the source such as a physician, hospital, etc.
You can provide this authorization by signing VA Form 21-4142. Federal law permits sources with information about you to release that information if you sign a single authorization to release all your information from all possible sources.
The Veterans Benefits Administration (VBA) uses VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), to request private medical records and information regarding the source of records in support of claims for compensation and/or pension benefits.