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About VA Form 21-4142a

Form name: General Release for Medical Provider Information to the Department of Veterans Affairs
Related to: Disability, Health care
Form last updated: August 31, 2021

When to use this form

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.

Downloadable PDF

Download VA Form 21-4142a (PDF)
  • VA Form 21-4142

    Form name: Authorization to Disclose Information to the Department of Veterans Affairs (VA)

    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)
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