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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 21-4142a 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.
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.
Authorize the release of non-VA medical information to VA (VA Forms 21-4142 and 21-4142a) When to use this form. Use this form if you want to give us permission to request your medical records and information from non-VA sources to support your benefit claim.
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.
VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits.