VA Form 21-4142a
General Release for Medical Records
Companion form to 21-4142. Lists additional healthcare providers.
General Release for Medical Records
In Plain English
Companion form to 21-4142. Lists additional healthcare providers.
Supplements Form 21-4142 when you need to list additional healthcare providers for the VA to contact.
Step-by-Step Guide
How to file 21-4142a
When to use this form
Only needed when you have more private healthcare providers than the 21-4142 has space for. This is a continuation sheet — not a standalone form.
You'll need to provide
- ✓Additional provider names and addresses
- ✓Dates of treatment at each additional facility
- ✓Your signature
Mail to
Department of Veterans Affairs, Claims Intake Center, PO Box 4444, Janesville, WI 53547-4444
Always submit together with Form 21-4142, never on its own.
Pro Tip
Most veterans only need the 21-4142. Only use this form if you have more than four private providers to list.
Which Form Do I Need?
21-4142 vs. 21-4142a — do I need both?
Authorization to Release Medical Records
Use this when
- •Use this to authorize the VA to contact each private provider
- •This is the primary form — most veterans only need this one
General Release for Medical Records
Use this when
- •Only needed when you have more providers than 21-4142 has space for
- •This is a continuation sheet, not a standalone form
Our recommendation
Most veterans only need 21-4142. If you have more than four private providers to list, also submit 21-4142a as a continuation sheet.
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