VA Form 21-4142a gives the Department of Veterans Affairs the names of the providers and facilities where you received treatment. Section I identifies the veteran by name, Social Security number, VA file number, date of birth and service number. Section II identifies the patient when the records are for someone other than the veteran. Section III asks, for each provider or facility, for its name, the conditions you were treated for, the dates of treatment and the provider's address. The form says it may be completed online or by hand, in ink with one letter per box, and gives the mailing address of the VA Evidence Intake Center in Janesville, Wisconsin.
| Question | Answer |
|---|---|
| Form Name | VA Form 21-4142a |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 99 |
| Other names | va form 21 4142a, va 21-4142a, general release for medical provider information |
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