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Click ‘Get Form’ to open it in the editor.
Begin with Section I, where you will enter the Veteran's identification details. Fill in the last name, first name, middle name, date of birth, VA file number, and social security number. If applicable, provide the claimant's information as well.
Move to Section II to list the source of pertinent information. Include the provider's name, address, and phone number along with the dates of treatment for your claimed conditions.
In Section III, read through the consent paragraphs carefully before signing. Ensure you check the appropriate statement regarding authorization for information release.
Finally, sign and date the form in Section III. If necessary, include a witness signature and their mailing address.
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The VA Form 21-4142 is generally valid for 12 months from the date signed. The VA Form 21-4142 clearly states at the heading EXPIRES that the authorization is good for 12 months from the date signed.
What is the purpose of the VA Form 21-4142?
VA forms are available at .va.gov/vaforms. 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.
What is the difference between VA Form 21-4142 and VA Form 21 4142a?
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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authorization and consent to release information to the
DEPARTMENT OF VETERANS AFFAIRS (VA). VA FORM. FEB 2012. 21-4142. Existing stocks of the VA Form 21-4142, JAN 2011, will be used. 1. LAST NAME - FIRST NAME
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