21-4142a
General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA form 21-4142a)
- Agency
- VA
- Revision
- 2024-08-18
- Fillable fields
- 96
Form 21-4142a: General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA form 21-4142a)
Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
How to fill out Form 21-4142a online
- 1
Open the form
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- 2
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- 3
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