What it is
VA Form 21-4142 is the Authorization to Disclose Information to VA. It is your written consent under HIPAA letting the VA contact a non-VA provider and ask for your treatment, hospitalization, psychotherapy, or outpatient records. VA Form 21-4142a is the companion General Release that captures the specific provider names, addresses, conditions treated, and dates of treatment.
When you use it
File it any time your claim relies on private medical care the VA does not already have: civilian primary care, private mental health treatment, urgent care visits, civilian surgeons, or treatment received before, during, or after service from anyone other than DoD or VA.
What to gather before you fill it out
A complete list of every private provider tied to the claim, each one's full address, the conditions they treated, and the start and end dates of treatment. List each provider separately on 21-4142a. The authorization is time-limited, so submit it close to filing.
How to submit
Upload through VA.gov, mail to the Evidence Intake Center, or fax to the number on the form. The VA will then send the request to the provider on your behalf as part of its duty to assist under 38 CFR 3.159(c)(1).
Common pitfalls
- Leaving the date range blank or open-ended. Fix: name a specific window; vague requests get rejected by provider records departments.
- Listing only the clinic group instead of the actual treating facility address. Fix: use the address where the records physically sit.
- Assuming VA will keep chasing the provider. Under 38 CFR 3.159(c)(1), VA must make reasonable efforts (generally one follow-up) and then notify you. If the records do not come back, you are responsible for obtaining them yourself.
- Forgetting to include 21-4142a. Without it, VA has consent but no provider to send it to.
Related forms
VA Form 21-4142a (General Release), VA Form 21-526EZ, VA Form 21-0966 (Intent to File).