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The VA Form 21-4142, officially titled "Authorization to Disclose Information to the Department of Veterans Affairs (VA)," plays a pivotal role in the processing of veterans' claims by allowing the VA to access crucial treatment records. Designed with a respondent burden of just 5 minutes, and an expiration date set for July 31, 2024, this document is integral for veterans seeking to expedite their claims and ensure the VA has all necessary information. By completing this form, veterans give their permission for the VA to obtain medical records from an array of sources including hospitals, clinics, and even employers, which might possess relevant information regarding their condition. This authorization is not limited to physical health records but extends to psychological and psychiatric reports, barring psychotherapy notes. The form underscores the importance of informed consent, requiring the veteran to read the Privacy Act and understand the implications of authorizing such disclosures. With options for electronic correspondence and a provision for electronic signatures under the Government Paperwork Elimination Act, the VA Form 21-4142 highlights the balance between efficient claims processing and the safeguarding of veterans' private information.

Preview - Va 21 4142 Form

OMB Control No. 2900-0858 Respondent Burden: 5 minutes Expiration Date: 07/31/2024

AUTHORIZATION TO DISCLOSE INFORMATION TO THE

DEPARTMENT OF VETERANS AFFAIRS (VA)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to provide your written authorization to obtain your treatment records, so the VA can get the information required to process your claim. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the relaynumber is 711. VA forms are available at www.va.gov/vaforms. For mailing information see page 3.

SECTION I - VETERAN IDENTIFICATION INFORMATION

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, and insert one letter per box, to help expedite processing of the form.

1. VETERAN'S NAME (First, Middle Initial, Last)

2.SOCIAL SECURITY NUMBER

5.VETERAN'S SERVICE NUMBER (If applicable)

3. VA FILE NUMBER (If applicable)

4. DATE OF BIRTH (MM/DD/YYYY)

6.MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

No. & Street

 

Apt./Unit Number

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. TELEPHONE NUMBER (Include Area Code)

 

 

 

 

 

 

8. E-MAIL ADDRESS (Optional)

 

 

 

I agree to receive electronic correspondence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

from VA in regards to my claim.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter International Phone Number (If applicable)

SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)

9. PATIENT'S NAME (First, Middle Initial, Last)

10. SOCIAL SECURITY NUMBER

11. VA FILE NUMBER (If applicable)

SECTION III - INFORMATION REGARDING SOURCE OF RECORD(S)

SOURCE OF RECORD(S):

•ALL medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment, and VA health care facilities,

•Social workers/rehabilitation counselors,

•Consulting examiners used by VA,

•Employers, insurance companies, workers' compensation programs, and

•Others who may know about my condition (family, neighbors, friends, public officials).

SECTION IV - RECORDS TO BE RELEASED TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of: All my medical records; including information related to my ability to perform tasks of daily living. This includes specific permission to release:

1.All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, but not limited to:

a.Psychological, psychiatric, or other mental impairment(s) excluding "psychotherapy notes" as defined in 45 C.F.R. §164.501,

b.Drug abuse, alcoholism, or other substance abuse,

c.Sickle cell anemia,

d.Records which may indicate the presence of a communicable or non-communicable disease; and tests for or records of HIV/AIDS,

e.Gene-related impairments (including genetic test results)

2.Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.

3.Information created within 12 months after the date this authorization is signed in Item 13, as well as past information.

YOU SHOULD NOT COMPLETE THIS FORM UNLESS YOU WANT THE VA TO OBTAIN PRIVATE TREATMENT RECORDS ON YOUR BEHALF. IF YOU HAVE ALREADY PROVIDED THESE RECORDS OR INTEND TO OBTAIN THEM YOURSELF, THERE IS NO NEED TO FILL OUT THIS FORM. DOING SO WILL LENGTHEN YOUR CLAIM PROCESSING TIME. THIS FORM IS NOT NEEDED TO REQUEST VA MEDICAL RECORDS.

IMPORTANT - In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees charged by a custodian to provide records requested."

JUL 2021

21-4142

PAGE 1

VA FORM

SUPERSEDES VA FORM 21-4142, MAR 2018.

VETERAN'S SOCIAL SECURITY NO.

SECTION V- AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE

12. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):

TO WHOM: The Department of Veterans Affairs (VA).

PURPOSE: Determining my eligibility for benefits, and whether I can manage such benefits.

EXPIRES: This authorization is good for 12 months from the date shown in Item 14.

•I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above in Section I.

•I understand that there are some circumstances in which this information may be re-disclosed to other parties (See page 2 for details).

•I may write to VA and my source(s) to revoke this authorization at any time (See page 2 for details).

•VA will give me a copy of this form, if I ask; I may also ask the source(s) to allow me to inspect or get a copy of material to be disclosed.

•I have read both pages of this form and agree to the disclosures above from the types of sources listed. See Patient Acknowledgment below.

13. SIGNATURE OF PERSON AUTHORIZING DISCLOSURE (Required)

14.DATE SIGNED (MM/DD/YYYY) (Required)

15.PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last)

16.RELATIONSHIP TO VETERAN/CLAIMANT (If other than self, please provide full name, title, organization, city, State, and ZIP code. All court appointments must include docket number, county, and State)

NOTE: This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical and other information under P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; 42 U.S.C. §290dd-2; 42 C.F.R. part 2, and State Law.

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the source to which this authorization is addressed may not be able to identify and locate your records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975 and still in effect.

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. Signing this form is voluntary, but failing to sign it, or revoking it before we receive necessary information could prevent an accurate or timely decision on your claim, and could result in denial or loss of benefits. Although the information we obtain with this form is almost never used for any purpose other than those stated above, the information may be disclosed by VA without your consent if authorized by Federal laws such as the Privacy Act.

Under the Government Paperwork Elimination Act (GPEA) (Public Law 105-277), the Office of Management and Budget (OMB) ensures that agencies, when practicable, provide for the option of electronic maintenance, submission of disclosure of information and for the use and acceptance of electronic signatures. GPEA states that electronic records submitted or maintained in accordance with the procedures developed by OMB, or electronic signature or other forms of electronic authentication used in accordance with such procedures, "shall not be denied legal effect, validity, or enforceability merely because such records are in electronic form" (Public Law 105-277, section 1707).

RESPONDENT BURDEN: We need this information and your written authorization to obtain your treatment records to help us get the information required to process your claim. Title 38, United States Code, allows us to ask for this information. You can provide this authorization by signing VA Form 21-4142. Federal law permits sources with information about you to release that information if you sign a single authorization to release all your information from all possible sources. We will make copies of it for each source. A few States, and some individual sources of information, require that the authorization specifically name the source that you authorize to release personal information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need you to sign more authorizations. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form. If you use the Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.

PATIENT ACKNOWLEDGMENT: I HEREBY AUTHORIZE the sources listed in Section IV, to release any information that may have been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will use this information in determining my eligibility to veterans benefits I have claimed. I understand that the source being asked to provide the Veterans Benefits Administration with records under this authorization may not require me to execute this authorization before it provides me with treatment, payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. I understand that once my source sends this information to VA under this authorization, the information will no longer be protected by the HIPAA Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a, and VA may disclose this information as authorized by law. I also understand that I may revoke this authorization in writing, at any time except to the extent a source of information has already relied on it to take an action. To revoke, I must send a written statement to the VA Regional Office handling my claim or the Board of Veterans' Appeals (if my claim is related to an appeal) and also send a copy directly to any of my sources that I no longer wish to disclose information about me. I understand that VA may use information disclosed prior to revocation to decide my claim.

NOTE: For additional information regarding VA Form 21-4142, refer to the following website: https://www.benefits.va.gov/privateproviders/.

VA FORM 21-4142, JUL 2021

PAGE 2

WHERE TO SEND YOUR WRITTEN CORRESPONDENCE

Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA recommends submitting correspondence electronically as this is the fastest method of receipt.

VA provides several tools to assist in electronic submission. To learn more about how to submit documents and claims electronically, visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to access.va.gov to digitally upload any correspondence using Direct Upload.

By visiting www.va.gov you can also check your claims status and learn about other VA benefits.

If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.

If you prefer to mail your correspondence, please use the related mailing address below.

 

 

COMPENSATION CLAIMS

PENSION & SURVIVORS BENEFIT CLAIMS

Department of Veterans Affairs

Department of Veterans Affairs

Evidence Intake Center

Pension Intake Center

PO Box 4444

PO Box 5365

Janesville, WI 53547-4444

Janesville, WI 53547-5365

 

 

FIDUCIARY

BOARD OF VETERANS' APPEALS

Department of Veterans Affairs

Department of Veterans Affairs

Fiduciary Intake

Board of Veterans' Appeals

PO Box 95211

PO Box 27063

Lakeland, FL 33804-5211

Washington, DC 20038

 

 

These addresses serve all United States and foreign locations.

VA FORM 21-4142, JUL 2021

PAGE 3

OMB Control No. 2900-0858 Respondent Burden: 5 minutes Expiration Date: 07/31/2024

GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION

TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to provide the name of the provider or facility you have received treatment from to the VA. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at www.va.gov/vaforms. After completing the form, mail to:

Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.

VA DATE STAMP

DO NOT WRITE IN THIS SPACE

SECTION I - VETERAN'S IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, and insert one letter per box, to help expedite processing of the form.

1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)

6. PATIENT'S NAME (First, Middle Initial, Last)

7. SOCIAL SECURITY NUMBER

8. VA FILE NUMBER

SECTION III - MEDICAL PROVIDER INFORMATION

 

9B. CONDITIONS YOU ARE BEING

 

9C. DATE(S) OF TREATMENT:

9A. PROVIDER OR FACILITY NAME

(Include the time period (MM/DD/YYYY)

 

TREATED FOR

for the treatment by the provider listed in Item 9A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

9D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

ZIP Code/Postal Code

10A. PROVIDER OR FACILITY NAME

10B. CONDITIONS YOU ARE BEING

TREATED FOR

10C. DATE(S) OF TREATMENT:

(Include the time period (MM/DD/YYYY)

for the treatment by the provider listed in Item 10A)

From:

To:

10D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

JUL 2021

21-4142a

 

PAGE 1

VA FORM

SUPERSEDES VA FORM 21-4142a, MAR 2018.

 

VETERAN'S SOCIAL SECURITY NO.

11A. PROVIDER OR FACILITY NAME

11B. CONDITIONS YOU ARE BEING

 

 

11C. DATE(S) OF TREATMENT:

(Include the time period (MM/DD/YYYY)

TREATED FOR

 

for the treatment by the provider listed in Item 11A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

ZIP Code/Postal Code

12A. PROVIDER OR FACILITY NAME

12B. CONDITIONS YOU ARE BEING

TREATED FOR

12C. DATE(S) OF TREATMENT:

(Include the time period (MM/DD/YYYY)

for the treatment by the provider listed in Item 12A)

From:

To:

12D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

ZIP Code/Postal Code

13A. PROVIDER OR FACILITY NAME

13B. CONDITIONS YOU ARE BEING

TREATED FOR

13C. DATE(S) OF TREATMENT:

(Include the time period (MM/DD/YYYY)

for the treatment by the provider listed in Item 13A)

From:

To:

13D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed may not be able to identify and locate your records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975 and still in effect.

RESPONDENT BURDEN: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/ PRAMain. If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact knowing it to be false.

VA FORM 21-4142a, JUL 2021

PAGE 2
Download Va 21 4142 PDF Form

Form Data

Fact Name Description
Purpose of Form VA 21-4142 This form is used to grant the Department of Veterans Affairs (VA) permission to obtain treatment records necessary to process claims for benefits. It serves as a written authorization allowing the VA to access private medical information from specified sources.
Expiration Date The form currently in use has an expiration date of 07/31/2024, indicating the time frame within which the form is considered valid and up-to-date as per the Office of Management and Budget (OMB) approval.
Respondent Burden Completing this form is estimated to take about 5 minutes, which includes the time to review instructions, locate information, and fill out the form. This estimate reflects the VA's consideration for the applicant’s time.
Privacy Act Notice Information collected on this form is protected under the Privacy Act of 1974 and the VA will not disclose it to sources other than those authorized under the act or Title 38, Code of Federal Regulations 1.576 for routine uses. It emphasizes the form's compliance with federal privacy laws.
Authority for Collection The basis for requesting personal information through this form is grounded in Title 38, United States Code, which allows the VA to ask for this information to facilitate the processing of claims. This legal foundation ensures that the collection of sensitive data is in line with statutory requirements.

Instructions on Utilizing Va 21 4142

Once you’ve decided to authorize the Department of Veterans Affairs (VA) to obtain private treatment records on your behalf using VA Form 21-4142, it’s important to follow a detailed set of instructions. This ensures that the VA can accurately and efficiently process your claim. Remember, this form should only be completed if you wish the VA to retrieve your treatment records for you. Completing this form when it's not necessary, or if you plan to provide the records yourself, may delay the claims process unnecessarily.

  1. Begin by reading the Privacy Act and Respondent Burden information provided on page 2 of the form to understand how your data will be used and protected.
  2. In Section I - Veteran Identification Information, enter your name in the format requested (First, Middle Initial, Last), your Social Security Number, VA File Number (if applicable), Date of Birth, Service Number (if applicable), and complete mailing address including ZIP Code. Ensure each piece of information is legibly printed in ink.
  3. Provide your Telephone Number and Email Address (email is optional) in the spaces provided. If you agree to receive electronic correspondence from the VA about your claim, indicate this here.
  4. In Section II, if the patient is someone other than the veteran, fill in the patient's Name, Social Security Number, and VA File Number.
  5. Section III does not require direct input but outlines the sources from which the VA may request your records. Review this section to understand what information may be collected.
  6. In Section IV, you are authorizing the VA to request and review all your medical records. You do not need to fill out anything in this section, but you should read it to understand the scope of the authorization.
  7. Section V - Authorization and Consent to Release Information to VA and Signature: If you wish to place limitations on the consent for certain records, specify these limitations in the space provided. If not, leave blank.
  8. Indicate to whom the information is being released (The Department of Veterans Affairs), the purpose of the disclosure, and note that the authorization is good for 12 months from the date signed.
  9. Sign and date the form in Item 13 and 14, respectively. Print your name in Item 15. If you are not the veteran or claimant, state your relationship to the veteran/claimant in Item 16 and provide any necessary details.

After completing this form, you should submit it according to the instructions provided in the Where to Send Your Written Correspondence section of VA Form 21-4142. Depending on the nature of your claim, you may submit this form by mail, in person at a VA regional office, or electronically for faster processing. Remember, signing and submitting this form is voluntary, but necessary for the VA to obtain the treatment records that could impact the success and timing of your claim. Ensure all information is accurate and complete to avoid delays.

Obtain Answers on Va 21 4142

FAQs about the VA Form 21-4142

  1. What is VA Form 21-4142 used for?

    This form is used to give the Department of Veterans Affairs (VA) your permission to request your private treatment records from healthcare providers. These records help the VA to process your claim by providing the necessary information to determine your eligibility for benefits.

  2. How do I fill out VA Form 21-4142?

    Begin by reading the Privacy Act and Respondent Burden notice. You can fill the form online or manually. If filling it out by hand, use ink and write legibly, placing one letter in each box to avoid delays in processing. Include your identification and the details about the healthcare providers or facilities where you received treatment. Finally, sign and date the form to give your consent for the VA to obtain your records.

  3. Is providing my Social Security Number (SSN) on VA Form 21-4142 mandatory?

    While providing your SSN is voluntary, it is highly recommended. Your SSN helps to ensure your records are accurately matched with your claim file, which is crucial for the VA to process your claim efficiently. Refusing to provide your SSN alone won’t result in benefits denial, but it may delay the processing of your claim.

  4. What should I do if I have already provided my medical records to the VA or plan to obtain them myself?

    If you have already submitted your medical records to the VA or intend to collect and submit them on your own, there is no need to fill out this form. Using the VA Form 21-4142 is recommended for veterans who prefer the VA to directly request their medical records from providers.

  5. How long is my consent valid after signing the VA Form 21-4142?

    Your consent is valid for 12 months from the date you sign the form. If you need to extend this period, you will need to fill out and submit a new form with a current date to renew your consent for the VA to request your medical records.

  6. Can I revoke my authorization for the VA to obtain my medical records?

    Yes, you can revoke your authorization at any time. To do so, you must write to the VA Regional Office handling your claim or to the Board of Veterans' Appeals if your claim is in the appeal process. Additionally, send a copy directly to any providers you no longer wish to disclose information about you. Keep in mind, revoking your consent may affect the VA’s ability to make a timely decision on your claim.

Common mistakes

Filling out the VA 21-4142 form is a vital step for veterans seeking to authorize the Department of Veterans Affairs (VA) to obtain their private treatment records. However, people often make mistakes during this process, which can delay the claim. Here are ten common mistakes to avoid:

  1. Not reading the instructions carefully before starting, which can lead to misunderstandings about the form's requirements.

  2. Incorrectly entering personal information such as the veteran's name, social security number, or VA file number, leading to processing delays.

  3. Failing to specify the mailing address correctly. Ensure the number and street are clearly written to prevent any correspondence issues.

  4. Leaving the telephone number and email address sections blank. While the email address is optional, providing these contacts could expedite the claim process.

  5. Misunderstanding the type of records that can be authorized for release to the VA. The form allows for the disclosure of a wide range of medical records, but exclusions apply.

  6. Not specifying the records to be released. It's important to allow the release of all relevant medical records, including those relating to mental health, substance abuse, and other conditions.

  7. Omitting information on medical providers or facilities. Accurate details including provider or facility name and address are crucial for the VA to obtain the necessary records.

  8. Forgetting to specify the conditions being treated and the periods of treatment. This information helps the VA understand the context of the medical records being requested.

  9. Not signing or dating the form. An unsigned or undated form will not be processed, delaying the benefits claim.

  10. Limiting the consent without a valid reason, which might restrict the VA's ability to obtain necessary records, impairing the claim's evaluation.

By avoiding these mistakes, you can ensure a smoother process for your claim. Remember, the goal of the VA 21-4142 form is to facilitate the collection of vital information needed to process your claim efficiently.

Documents used along the form

When completing VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), individuals often need to submit additional documents to provide comprehensive information about their health and benefits eligibility. Understanding these associated documents can streamline the process of claims and ensure timely feedback.

  • VA Form 21-0781 - Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). This form is used to detail any stressor events that contributed to PTSD and is essential for establishing a service connection.
  • VA Form 21-4142a - General Release for Medical Provider Information to the VA. Complements Form 21-4142 by specifying the medical providers or facilities that hold the veteran's medical records.
  • VA Form 21-2680 - Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. Required to evaluate if a veteran is eligible for additional benefits due to being housebound or needing regular aid.
  • VA Form 21-22 - Appointment of Veterans Service Organization as Claimant's Representative. Used to appoint a Veterans Service Organization to act on the veteran's behalf in preparation, presentation, and prosecution of claims for VA benefits.
  • VA Form 21-526EZ - Application for Disability Compensation and Related Compensation Benefits. This form initiates the process for disability compensation, offering veterans a path to file their claims electronically or by paper.
  • VA Form 21-4502 - Application for Automobile or Other Conveyance and Adaptive Equipment. For veterans seeking benefits related to vehicle purchase and adaptive equipment due to service-connected disabilities.
  • VA Form 10-10EZ - Application for Health Benefits. This form is the application for enrolling in the VA health care system, ensuring veterans have access to health services.

Together, these forms play crucial roles in providing veterans with access to the benefits and support they deserve. By gathering and submitting the appropriate documentation, the VA can more accurately and swiftly process claims, paving the way for veterans to receive the necessary assistance. It's essential to understand each document's purpose and how it supports the veteran's claim or healthcare needs.

Similar forms

When navigating the complexities of form submissions within the context of veteran affairs or related areas, one can find that the VA Form 21-4142, known for authorizing the disclosure of information to the Department of Veterans Affairs (VA), shares similarities with several other documents. These forms serve related purposes, facilitating the exchange or collection of information for various benefits, claims, or services. Here’s a closer look at forms that share a common ground with VA Form 21-4142:

  • VA Form 21-526EZ: Application for Disability Compensation and Related Compensation Benefits. Similar to VA Form 21-4142, this form is used by veterans to initiate claims for benefits. Both require personal identification information and are integral in processing claims with the VA.
  • VA Form 10-5345: Request for and Authorization to Release Medical Records or Health Information. This form is closely related to VA Form 21-4142 as both involve the authorization to release medical or health-related information, but VA Form 10-5345 is more broadly applicable beyond the VA.
  • Standard Form 180 (SF-180): Request Pertaining to Military Records. Though SF-180 is primarily to request military records, it parallels VA Form 21-4142 in facilitating access to documents necessary for processing claims or benefits.
  • VA Form 21-0781: Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder. Like Form 21-4142, which gathers medical records, Form 21-0781 collects specific information to support a particular type of claim, showing how various forms can accumulate comprehensive data to support a veteran’s claim.
  • VA Form 21-0966: Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC. This form, while a precursor to a formal claim, shares Form 21-4142’s objective of initiating a process for veterans to claim their benefits.
  • Health Insurance Portability and Accountability Act (HIPAA) Release Form: While not a VA-specific form, the HIPAA Release Form has a purpose akin to VA Form 21-4142, focusing on the authorization to disclose healthcare information, ensuring privacy and compliance.
  • VA Form 22-5490: Dependents’ Application for VA Education Benefits. Although centered on educational benefits, this form connects with VA Form 21-4142 through its aim to secure benefits for individuals, necessitating detailed personal information for processing.
  • VA Form 21-4502: Application for Automobile or Other Conveyance and Adaptive Equipment. It relates to VA Form 21-4142 in terms of being application-based and requiring detailed personal identification to ensure benefits are correctly allocated.
  • VA Form 21-686c: Declaration of Status of Dependents. This form complements VA Form 21-4142 by providing the VA with information on a veteran’s dependents, which is crucial for accurately determining the level of benefits a veteran is eligible for.

Overall, while each of these forms serves unique functions, from claiming PTSD benefits to requesting education benefits or submitting intent to file a claim, they collectively embody the VA’s commitment to supporting veterans through a structured, informational framework. This interconnectedness ensures veterans have access to a comprehensive suite of benefits befitting their service and sacrifices.

Dos and Don'ts

When filling out the VA Form 21-4142, it is crucial to adhere to certain guidelines to ensure the process is completed correctly and efficiently. Below are important do's and don'ts to keep in mind:

  • Do read the Privacy Act and Respondent Burden notices on page 2 before you start filling out the form. This helps you understand the purpose and use of the information you provide.
  • Do complete the form online if possible. Filling out the form online can help reduce errors and ensure that the information is processed more quickly.
  • Do print information neatly and legibly if you are filling out the form by hand. This prevents delays that can occur due to unreadable information.
  • Do include one letter or digit per box if completing the form by hand, to avoid confusion and expedite the processing of your form.
  • Do review all the information carefully before submitting the form, to confirm accuracy and completeness.
  • Don't leave any required fields blank. Incomplete forms can lead to delays in the processing of your claim.
  • Don't provide more information than what is requested on the form. Unnecessary information can complicate the processing of your form.
  • Don't forget to sign and date the form. Unsigned forms will not be processed.

Being thorough and precise when completing the VA Form 21-4142 is crucial for the timely and accurate processing of your request. Attention to detail can help avoid delays in obtaining benefits or services.

Misconceptions

Many individuals have misunderstandings about the VA 21-4142 form, which can lead to confusion and potential delays in processing VA claims. Here are some common misconceptions:

  • Any VA form will suffice to release medical records. This is incorrect. The VA 21-4142 form is specifically designed to authorize the release of medical information to the Department of Veterans Affairs (VA). Without this form, the VA may not obtain the necessary records to process a claim.

  • Completing the form guarantees faster claim processing. While the form permits the VA to request medical records on a veteran's behalf, it does not necessarily speed up the claim process. The form helps ensure that the VA can acquire needed records, but processing times can still vary widely.

  • The form is required for VA medical records. This misconception can lead to unnecessary paperwork. In reality, the VA Form 21-4142 is not needed to request medical records from VA healthcare facilities. The VA already has access to records from its own system.

  • The authorization is permanent. The truth is, the authorization provided by VA Form 21-4142 is only valid for 12 months from the date of signing. If the information is needed beyond this period, a new authorization must be completed.

  • Signing the form waives all rights to privacy. Signing the form does authorize the release of specific medical records to the VA, but it does not waive all privacy rights. Information is still protected under federal law, and veterans have the right to limit what information is shared.

  • Personal attendance at a VA office is required to submit this form. Veterans can indeed submit VA Form 21-4142 by mail, in person, or electronically. The availability of electronic submission offers convenience and can often lead to faster receipt and processing.

Understanding the specifics of the VA 21-4142 form can help veterans and their families navigate the VA claims process more effectively, reducing delays and ensuring that their privacy rights are respected.

Key takeaways

When dealing with the VA 21-4142 form, designed to authorize the disclosure of information to the Department of Veterans Affairs (VA), there are several key takeaways to ensure the process is comprehensive and effective. Understanding these elements can streamline claims and foster a better exchange of necessary information.

  • Prior to filling out the form, read the Privacy Act and Respondent Burden statements carefully to understand the implications of the authorization and the estimated time to complete the form.
  • The form is a vital document for veterans seeking to have their private medical records released to the VA, which can significantly expedite the claim processing time by allowing the VA direct access to required medical documentation.
  • Ensure all personal identification information in Section I is filled out correctly, including the veteran's name, social security number, service number if applicable, and contact information. Accuracy in this section helps the VA to accurately associate the form with the correct claim file.
  • Section IV of the form should be carefully reviewed and filled out, as it specifies the types of records to be disclosed, including all medical records and any specific conditions or treatments. This comprehensive approach ensures no necessary information is overlooked.
  • The form is not required if medical records have already been submitted to the VA or if the veteran intends to provide them independently. Duplicate submissions can delay the processing of claims.
  • Authorization provided by signing the form is valid for 12 months from the date indicated in Item 14. If there are changes in the authorization or it needs to be revoked for any reason, this must be done in writing and sent to the VA.

Incorporating these key points when handling the VA 21-4142 form not only helps in ensuring that the veterans' claims are accurately and efficiently processed but also protects the veterans' rights to privacy and informed consent in the release of their medical information.

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