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The document is a VA Form 21-4142, which serves as an authorization for veterans to disclose their medical records to the Department of Veterans Affairs (VA). It outlines the types of medical information that can be released, including records related to mental health, substance abuse, and other impairments. The form requires personal identification details from the veteran and specifies that it is voluntary but necessary for processing claims. It also includes privacy notices and instructions for completing the form.

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Versions	Form popularity	Fillable & printable
2021	4 Satisfied (61 Votes)
2018	4.8 Satisfied (95 Votes)
2014	4 Satisfied (36 Votes)
2012	4 Satisfied (63 Votes)
2004	4.3 Satisfied (190 Votes)

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What date does the VA form 21-4142 expire?

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.

Where to send VA form 21 4142?

After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. NOTE: You may complete the form online or by hand.

How do I submit a claim to TDIU?

You can apply online using VA.gov. To apply for TDIU, you must complete VA Form 21-8940, Veterans Application Based on Unemployability.

What is the difference between 4142 and 4142a?

While the VA has direct access to medical records from VA facilities, it does not automatically retrieve records from private doctors, specialists, or hospitals. Thats where VA Forms 21-4142 (Authorization to Disclose Information) and 21-4142a (General Release for Medical Provider Information) come into play.

Who completes the VA form 21 4192?

Your most recent employer must complete and submit this form.

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Who must the VA form 21 4192 be sent to?

Based on the information you provide in Form 21-8940, the VA will automatically generate and send a VA Form 21-4192 to your most recent employer. The VA will send you a copy as well. At that point, its a good idea to work with your former employer directly to make sure they complete and submit the form on time.

What is the VA Form 21-4142 used for?

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.

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