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NOTE - PLEASE READ THE ENTIRE FORM (both pages) BEFORE SIGNING IN ITEM 11 BELOW - vba va 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with SECTION I, where you will authorize the release of your medical records. Ensure you check all relevant boxes that apply to your treatment history.
- Proceed to SECTION II and fill in your personal identification details, including your last name, first name, middle name, date of birth, and Social Security number or VA file number.
- In SECTION III, provide the patient identification for records being requested. This includes filling out the same personal details for the patient as required.
- SECTION IV requires you to list all sources of medical records. Be thorough in identifying hospitals, clinics, and other providers who have treated you.
- Finally, in SECTION V, review the authorization and consent section carefully before signing. Make sure to include your signature and date in Item 11.
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va form 21 4142a pdf fillable
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