Instructions for VA Form 21-4142: Authorization to Disclose Information to VA
What Is VA Form 21-4142 Used For?
The Department of Veterans Affairs (VA) Form 21-4142, Authorization to Disclose Information to VA, gives VA permission to obtain a veteran’s medical treatment records from non-VA sources, such as from a private doctor or hospital.
It is important to note that you should only complete this form if you want VA to obtain private medical records on your behalf. If you already provided these records to VA or will obtain them on your own, it is not necessary to fill out this form as it may lengthen the claims process.
How to Fill Out VA Form 21-4142
Veterans can fill out VA Form 21-4142 online or by hand. Once complete, the document can be submitted by mail, in-person at your local VA Regional Office, or electronically. VA recommends submitting this form online as it is the fastest method of receipt.
The following are VA Form 21-4142 instructions and tips:
Section I and II: Identification Information
In Section I, you can provide your identifying information, such as your name, social security number, VA file number, date of birth, service number, mailing address, telephone number, and email address. If you are not the veteran, your information should be provided in Section II.
Section III: Information Regarding Source of Records
In Section III, VA lists potential sources from which it may retrieve your medical information and documents. These include:
- Medical sources, such as hospitals, clinics, physicians, labs, and VA health care facilities
- Mental health, correctional, and addiction treatment records
- Social workers and rehabilitation counselors
- VA consulting examiners
- Employers, insurance companies, and workers’ compensation programs
- Anyone else who may know about your service-related condition (family, friends, neighbors, etc.)
Section IV: Records to Be Released to VA
Section IV details the types of records and private medical information you are disclosing to VA. Specifically, you are allowing VA to access:
- All information related to treatment, hospitalization, and outpatient care for your service-related condition
- Information regarding your ability to perform tasks of daily living and your ability to work
- Any medical information created within 12 months after the date of signature on this form.
Section V: Authorization to Release Information to VA and Signature
To confirm the previous sections, veterans must officially sign and date VA Form 21-4142 in Section V. You can also list any limitations you have with the disclosure in box 12. If the person authorizing the disclosure is not the veteran or claimant (e.g., an accredited attorney), they must detail their personal information and relationship to the client in box 16.
Upon signing this document, you are giving VA authorization to access your private medical records for 12 months from the date of your signature. Importantly, you can write to VA to revoke this authorization at any time.
Need Assistance with Your Claim or Appeal?
If you need assistance filling out VA Form 21-4142 or if you need help appealing a VA decision, Chisholm Chisholm & Kilpatrick LTD may be able to help. The accredited representatives at CCK have decades of collective experience helping veterans secure the benefits they deserve.
Reach out to CCK today for a free case evaluation with a member of our team.
