Va form 21 4142 2012-2026

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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, estimated completion time, and provides sections for veteran identification, source of pertinent information, and consent to release information. The form emphasizes the importance of accurate information for processing claims and includes privacy notices regarding the handling of personal data.

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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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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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Where to send VA form 21 4142a?

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 long is a VA form 21/22 good for?

In such cases, the assignment of the service organization as the veterans representative is valid for only five years from the date the claimant signs this form for purposes restricted to the verification match. Signed and accepted subject to the foregoing conditions.

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

VA Form 21-4142 and VA Form 21-4142a While VA Form 21-4142 authorizes the Department to access a veterans non-VA treatment medical records, Form 21-4142a must be completed at the same time to disclose all medical providers or facilities that administered medical treatment to the veteran.Apr 23, 2024

What date does the VA form 21-4142 expire?

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.

How long is a certificate of eligibility valid?

The initial COE application process includes a firearms eligibility criminal background check and issuance of a certificate, which is valid for one year. Thereafter, the COE must be renewed annually.

how to fill out va form 21 4138

VA Form 21-4142a VA Form 21-4142a PDF VA Form 21-4142 fillable VA Form 21-4142a download VA Form 21-4142a printable VA Form 21 4142 and 21-4142a Va form 21 4142a instructions VA Form 21 4142 online

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What is a 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.Dec 18, 2025