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About VA Form 21-4142

Form name: Authorization to Disclose Information to the Department of Veterans Affairs (VA)
Related to: Disability, Health care
Form last updated: May 2023

When to use this form

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.

Downloadable PDF

Download VA Form 21-4142 (PDF)

Online tool

You can submit your authorization online instead of sending us the paper form.

Go to the online tool