VA Form 21-4142

Step 1 of 5

			VA DATE STAMP (DO NOT WRITE IN THIS SPACE)
AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. 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). VA forms are available at www.va.gov/vaforms. For mailing information see page 3.

SECTION I - VETERAN IDENTIFICATION INFORMATION

Note: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, and insert one letter per box, to help expedite processing of the form.

1. VETERAN'S NAME (First, Middle Initial, Last)

I 1. First Name

I 1. Middle Initial

I 1. Last Name

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

4. DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable)

6. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

7. TELEPHONE NUMBER (Include Area Code)

International Phone Number

Enter International Phone Number (If applicable)

8. E-MAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)

9. PATIENT'S NAME (First, Middle Initial, Last)

9. First Name

9. Middle Initial

9. Last Name

10. SOCIAL SECURITY NUMBER

11. VA FILE NUMBER (If applicable)

SECTION III - INFORMATION REGARDING SOURCE OF RECORD(S)

SOURCE OF RECORD(S):

ALL medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment, and VA health care facilities,
Social workers/rehabilitation counselors,
Consulting examiners used by VA,
Employers, insurance companies, workers' compensation programs, and
Others who may know about my condition (family, neighbors, friends, public officials).

SECTION IV - RECORDS TO BE RELEASED TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of: All my medical records; including information related to my ability to perform tasks of daily living. This includes specific permission to release:

All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, but not limited to:
1. Psychological, psychiatric, or other mental impairment(s) excluding "psychotherapy notes" as defined in 45 C.F.R. §164.501,
2. Drug abuse, alcoholism, or other substance abuse,
3. Sickle cell anemia,
4. Records which may indicate the presence of a communicable or non-communicable disease; and tests for or records of HIV/AIDS,
5. Gene-related impairments (including genetic test results)
Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
Information created within 12 months after the date this authorization is signed in Item 13, as well as past information.

YOU SHOULD NOT COMPLETE THIS FORM UNLESS YOU WANT THE VA TO OBTAIN PRIVATE TREATMENT RECORDS ON YOUR BEHALF. IF YOU HAVE ALREADY PROVIDED THESE RECORDS OR INTEND TO OBTAIN THEM YOURSELF, THERE IS NO NEED TO FILL OUT THIS FORM. DOING SO WILL LENGTHEN YOUR CLAIM PROCESSING TIME. THIS FORM IS NOT NEEDED TO REQUEST VA MEDICAL RECORDS.

IMPORTANT: In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees charged by a custodian to provide records requested."

SECTION V- AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE

12. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):

TO WHOM: The Department of Veterans Affairs (VA). PURPOSE: Determining my eligibility for benefits, and whether I can manage such benefits. EXPIRES: This authorization is good for 12 months from the date shown in Item 14.

I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above in Section I.
I understand that there are some circumstances in which this information may be re-disclosed to other parties (See page 2 for details).
I may write to VA and my source(s) to revoke this authorization at any time (See page 2 for details).
VA will give me a copy of this form, if I ask; I may also ask the source(s) to allow me to inspect or get a copy of material to be disclosed.
I have read both pages of this form and agree to the disclosures above from the types of sources listed. See Patient Acknowledgment below.

13. SIGNATURE OF PERSON AUTHORIZING DISCLOSURE (Required)

14. DATE SIGNED (MM/DD/YYYY) (Required)

15. PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last)

15. First Name

15. Middle Initial

15. Last Name

16. RELATIONSHIP TO VETERAN/CLAIMANT (If other than self, please provide full name, title, organization, street, city, State, and ZIP code. All court appointments must include docket number, county, and State)

NOTE: This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical and other information under P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; 42 U.S.C. §290dd-2; 42 C.F.R. part 2, and State Law.

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of material fact knowing it to be false.

If you do not revoke this authorization, it will automatically expire in 12 months from the date you sign and date the form. Signing this form is voluntary, but failing to sign it, or revoking it before we receive necessary information could prevent an accurate or timely decision on your claim, and could result in denial or loss of benefits. Although the information we obtain with this form is almost never used for any purpose other than those stated above, the information may be disclosed by VA without your consent if authorized by Federal laws such as the Privacy Act.

Under the Government Paperwork Elimination Act (GPEA) (Public Law 105-277), the Office of Management and Budget (OMB) ensures that agencies, when practicable, provide for the option of electronic maintenance, submission of disclosure of information and for the use and acceptance of electronic signatures. GPEA states that electronic records submitted or maintained in accordance with the procedures developed by OMB, or electronic signature or other forms of electronic authentication used in accordance with such procedures, "shall not be denied legal effect, validity, or enforceability merely because such records are in electronic form" (Public Law 105-277, section 1707).

PATIENT ACKNOWLEDGMENT: I HEREBY AUTHORIZE the sources listed in Section IV, to release any information that may have been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will use this information in determining my eligibility to veterans benefits I have claimed. I understand that the source being asked to provide the Veterans Benefits Administration with records under this authorization may not require me to execute this authorization before it provides me with treatment, payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. I understand that once my source sends this information to VA under this authorization, the information will no longer be protected by the HIPAA Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a, and VA may disclose this information as authorized by law. I also understand that I may revoke this authorization in writing, at any time except to the extent a source of information has already relied on it to take an action. To revoke, I must send a written statement to the VA Regional Office handling my claim or the Board of Veterans' Appeals (if my claim is related to an appeal) and also send a copy directly to any of my sources that I no longer wish to disclose information about me. I understand that VA may use information disclosed prior to revocation to decide my claim.

NOTE: For additional information regarding VA Form 21-4142, refer to the following website: https://www.benefits.va.gov/privateproviders/.

PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the source to which this authorization is addressed may not be able to identify and locate your records, and provide a copy to VA. 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. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975 and still in effect.

RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-0858, and it expires August 31, 2027. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0858 in any correspondence. Do not send your completed VA Form 21-4142 to this email address.

COMPENSATION CLAIMS	PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs Evidence Intake Center PO Box 4444 Janesville, WI 53547-4444	Department of Veterans Affairs Pension Intake Center PO Box 5365 Janesville, WI 53547-5365
FIDUCIARY	BOARD OF VETERANS' APPEALS
Department of Veterans Affairs Fiduciary Intake PO Box 95211 Lakeland, FL 33804-5211	Department of Veterans Affairs Board of Veterans' Appeals PO Box 27063 Washington, DC 20038

			VA DATE STAMP (DO NOT WRITE IN THIS SPACE)
GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. 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. VA forms are available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION

1. VETERAN'S NAME (First, Middle Initial, Last)

1. First Name

1. Middle Initial

1. Last Name

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)

6. PATIENT'S NAME (First, Middle Initial, Last)

6. First Name

6. Middle Initial

6. Last Name

7. SOCIAL SECURITY NUMBER

8. VA FILE NUMBER

SECTION III - MEDICAL PROVIDER INFORMATION

9A. PROVIDER OR FACILITY NAME

9B. CONDITIONS YOU ARE BEING TREATED FOR

9C. DATE(S) OF TREATMENT:
(Include the time period (MM/DD/YYYY) for the treatment by the provider listed in Item 9A)

From:

To:

9D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

10A. PROVIDER OR FACILITY NAME

10B. CONDITIONS YOU ARE BEING TREATED FOR

10C. DATE(S) OF TREATMENT:
(Include the time period (MM/DD/YYYY) for the treatment by the provider listed in Item 10A)

From:

To:

10D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

11A. PROVIDER OR FACILITY NAME

11B. CONDITIONS YOU ARE BEING TREATED FOR

11C. DATE(S) OF TREATMENT:
(Include the time period (MM/DD/YYYY) for the treatment by the provider listed in Item 10A)

From:

To:

11D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

12A. PROVIDER OR FACILITY NAME

12B. CONDITIONS YOU ARE BEING TREATED FOR

12C. DATE(S) OF TREATMENT:
(Include the time period (MM/DD/YYYY) for the treatment by the provider listed in Item 10A)

From:

To:

12D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

13A. PROVIDER OR FACILITY NAME

13B. CONDITIONS YOU ARE BEING TREATED FOR

13C. DATE(S) OF TREATMENT:
(Include the time period (MM/DD/YYYY) for the treatment by the provider listed in Item 10A)

From:

To:

13D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code

Postal Code

PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed may not be able to identify and locate your records, and provide a copy to VA. 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. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975 and still in effect.

RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-0858, and it expires August 31, 2027. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0858 in any correspondence. Do not send your completed VA Form 21-4142a to this email address.

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact knowing it to be false.

VA FORM 21-4142

AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

WHERE TO SEND YOUR WRITTEN CORRESPONDENCE

GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

AUTHORIZATION TO DISCLOSE INFORMATION TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA)

GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION
TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)