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The document is a VA Form 21-4142, which is an authorization and consent form for veterans to release their medical treatment information to the Department of Veterans Affairs (VA). It outlines the respondent burden, which is estimated at 5 minutes, and provides instructions for completing the form. The form collects personal information about the veteran and any claimants, details about medical treatment sources, and includes a consent section regarding the release of sensitive health information. It emphasizes the voluntary nature of providing Social Security Numbers and explains privacy protections under federal law.

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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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How long is a VA Form 21-4142 good for?

When to use this form. Use VA Form 21-4192 if youre a Veteran and you need your most recent employer to send us information so you can apply for Individual Unemployability disability benefits. Your most recent employer must complete and submit this form.

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.

What is the difference between 100% VA disability and unemployability?

What is the Difference? The monthly compensation amount for unemployability is equal to that of a 100% disability rating. However, the qualifying criteria for unemployability are different than the requirements for a 100% rating.

What is the difference between VA form 21-4142 and 21 4142a?

The VA Form 21-4142 is valid for 12 months from the date signed. It is permissible to authorize release of, and disclose, information created after the consent is signed.

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.

how to fill out va form 21 4138

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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.

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How long is a VA Form 21-4142 good for?

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What is the difference between 100% VA disability and unemployability?

What is the difference between VA form 21-4142 and 21 4142a?

What date does the VA form 21-4142 expire?

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What is the difference between 4142 and 4142a?

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