21-4142
Authorization to Disclose Information to VA
Use this when
- Authorizes a non-VA source to disclose your private health information to VA
- Covers the consent VA needs before requesting the records
VA Form 21-4142a
Medical Provider Information
Lists the non-VA providers and treatment details VA needs to request your records.
21-4142a
Supporting Your Claim
What this form does
Lists the non-VA providers and treatment details VA needs to request your records.
Provides names, addresses, conditions, and treatment dates for non-VA medical providers. VA generally uses it with Form 21-4142, which supplies your authorization.
Official VA title: General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
VA revision August 18, 2024 · Links verified against VA.gov August 10, 2026
Use it when: When you want VA to request records from a private doctor, hospital, or other non-VA provider. Follow the current VA instructions for Forms 21-4142 and 21-4142a together.
Preparation route
How to use 21-4142a
Every preparation step stays open so you can scan the whole job before starting.
Do now · 01
Before you start
Use this form when: When you want VA to request records from a private doctor, hospital, or other non-VA provider. Follow the current VA instructions for Forms 21-4142 and 21-4142a together.
Waypoint · 02
Complete the form
- Provider or facility names and full addresses
- Medical conditions treated
- Treatment date ranges
Go next · 03
Submit the form
Available methods
- Online
- Mail to
- Department of Veterans Affairs, Claims Intake Center, PO Box 4444, Janesville, WI 53547-4444
- Submission note
- Use VA’s combined online authorization flow, or follow the current instructions on Forms 21-4142 and 21-4142a when filing on paper.
Field note
VA’s online authorization flow covers both forms. If you use paper, review both official form pages before submitting so the provider details and authorization stay together.
Which form fits?
21-4142 and 21-4142a — how do they work together?
21-4142a
Medical Provider Information
Use this when
- Identifies each non-VA provider or facility that has your records
- Lists provider addresses, treatment conditions, and treatment dates so VA can request the right records
Our recommendation
When you want VA to request private medical records, complete both roles: 21-4142 provides authorization and 21-4142a provides the medical-provider details. VA's online authorization flow collects the same information.
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