VA Form 21-4142: Authorization to Disclose Information to the Department of Veterans Affairs (VA)

In Box 1, enter the veteran's name (First, Middle Initial, Last).

Box 2 is the Social Security Number, Box 3 is the VA file number (if applicable) and Box 4 is the date of birth (MM/DD/YYYY).

Box 5 is the veteran's service number (if applicable).

In Box 6, enter the mailing address: Number and street or rural route, P. O. Box, City, State/Province, ZIP Code/Postal Code and Country, with an Apt./Unit Number.

In Box 7, enter the telephone number (include area code).

Section II, Patient Identification for Records VA Is Requesting, applies if other than veteran: Box 9 is the patient's name (First, Middle Initial, Last), Box 10 is the Social Security Number and Box 11 is the VA file number (if applicable).

In Box 12, write the limitation if your consent to this information is limited. If this space is left blank, there is no limitation to records.

Box 13, the signature of the person authorizing disclosure, is required, and so is Box 14, the date signed (MM/DD/YYYY).

I have read both pages of this form and agree to the disclosures from the types of sources listed.

In Box 15, print the name of the person signing (First, Middle Initial, Last).

Box 16 is the relationship to veteran/claimant. If other than self, provide full name, title, organization, street, city, State, and ZIP code. All court appointments must include docket number, county, and State.

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. This form is not needed to request VA medical records.

You 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, you must send a written statement to the VA Regional Office handling your claim or the Board of Veterans' Appeals (if your claim is related to an appeal) and also send a copy directly to any of your sources that you no longer wish to disclose information about you.

VA Form 21-4142 is the Authorization to Disclose Information to the Department of Veterans Affairs (VA), AUG 2024, which supersedes VA Form 21-4142, JUL 2021. 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, you can contact VA online through Ask VA: https://ask.va.gov/ or call VA toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. For mailing information see page 3.

Use VA Form 21-4142a, the General Release for Medical Provider Information to the Department of Veterans Affairs (VA), to provide the name of the provider or facility you have received treatment from to the VA.

If you prefer to mail your correspondence, use the related mailing address. Compensation claims: Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444. Pension & Survivors Benefit Claims: Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. Fiduciary: Department of Veterans Affairs, Fiduciary Intake, PO Box 95211, Lakeland, FL 33804-5211. Board of Veterans' Appeals: Department of Veterans Affairs, Board of Veterans' Appeals, PO Box 27063, Washington, DC 20038. These addresses serve all United States and foreign locations.

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

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.