About VA Form 21-4142a
- Related to: Disability, Health care
- Form last updated: June 2022
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 PDFDownload VA Form 21-4142a (PDF)
You can submit your authorization online instead of sending us the paper form.Go to the online tool
Related forms and instructions
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)
Helpful links related to VA Form 21-4142a
Securely review, download, and share your medical records.
Find out if you qualify for compensation for a presumptive disability or other service-connected conditions.
Find out how to file a claim for disability compensation or increased disability compensation.