Form to release information from non-VA medical providers to VA
- Form name:General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA form 21-4142a)
- Form revision date: August 2024
- Related to: Disability, Health care
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
Online tool
You can submit your authorization online instead of sending us the paper form.
Related forms and instructions
VA Form 21-4142
Form name: Authorization to Disclose Information to the Department of Veterans Affairs (VA) (VA Form 21-4142)
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.