Section I: Veteran identification
Veteran's name, Social Security number, VA file number, date of birth, service number, mailing address, phone and an optional email address, with a box to agree to electronic correspondence about the claim.
21-4142
Authorization to Disclose Information to the Department of Veterans Affairs (VA) (VA Form 21-4142)
- Agency
- VA
- Revision
- August 2024
- Fillable fields
- 140
- Pages
- 5
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-4142: Authorization to Disclose Information to VA
VA Form 21-4142 is the U.S. Department of Veterans Affairs Authorization to Disclose Information to the Department of Veterans Affairs (VA). VA's form page says to use it to give VA permission to obtain your personal information from a non-VA source like a private doctor or hospital, such as records of medical treatment, hospitalizations, psychotherapy or outpatient care.
The form itself says it is for when you want VA to obtain private treatment records on your behalf. If you have already provided those records or intend to get them yourself, it says there is no need to fill it out and that doing so lengthens claim processing time. It also says the form is not needed to request VA medical records.
The PDF includes VA Form 21-4142a, General Release for Medical Provider Information, where each provider or facility is named. VA's page says you can submit the authorization online instead of the paper form. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21-4142
Section II: patient, if not the Veteran
Name, Social Security number and VA file number of the patient whose records VA is requesting, when that person is not the Veteran.
Sections III and IV: sources and records
Section III lists the kinds of sources covered, from medical providers and counselors to employers, insurers and people who know about the condition. Section IV lists the records released, with psychotherapy notes excluded.
Section V: limits, consent and signature
Item 12 is for any limit on consent, and the form says a blank space means no limitation to records. Items 13 to 16 hold the signature, date signed, printed name and relationship to the Veteran.
Pages 2 and 3: notices and addresses
The patient acknowledgment, the Privacy Act notice, and mailing addresses for compensation claims, pension and survivors claims, fiduciary mail and the Board of Veterans' Appeals.
VA Form 21-4142a: provider details
The attached General Release names up to five providers or facilities, each with the conditions treated, the dates of treatment and the provider's street address.
How to file VA Form 21-4142
- 1
Check whether the form is needed
The form says to complete it only if you want VA to obtain private treatment records for you, and that it is not needed to request VA medical records.
- 2
Fill in Sections I and II
Identify the Veteran in Section I. Section II is completed only if the records belong to a patient other than the Veteran.
- 3
Note any limit on the records
Write any limitation on consent in Item 12. The form says that if this space is left blank, there is no limitation to records.
- 4
Sign and date Section V
The form marks Items 13 and 14, the signature and date signed, as required. It says the authorization is good for 12 months from the date shown in Item 14.
- 5
List providers on VA Form 21-4142a
On the attached VA Form 21-4142a, name each provider or facility, the conditions treated, the treatment dates and the address.
- 6
Send it to VA
The form says documents may be submitted by mail, in person at a VA regional office or electronically, and that VA recommends electronic submission as the fastest method of receipt.
Why fill Form 21-4142 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and what happens next
Compensation claims by mail
Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.
Pension and survivors claims by mail
Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365.
Online
VA's form page says you can submit the authorization online. The form also points to va.gov/disability/upload-supporting-evidence and to Direct Upload at access.va.gov.
How long it lasts
The form says the authorization expires 12 months from the date signed unless revoked, and that it can be revoked in writing to the VA Regional Office handling the claim, with a copy sent to each source.
Fees for records
The form quotes 38 C.F.R. §3.159(c): "VA will not pay any fees charged by a custodian to provide records requested."
Help with the form
The form lists Ask VA at ask.va.gov, the toll-free number 1-800-827-1000 (TTY: 711), and accredited representatives at benefits.va.gov/vso.
Related forms
21-4142a
General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA form 21-4142a)
96 fields, 2 pages
21-526EZ
Application for Disability Compensation and Related Compensation Benefits
345 fields, 15 pages
20-0995
Decision Review Request: Supplemental Claim
136 fields, 7 pages
21-0781
Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s)
124 fields, 7 pages
21-4138
Statement in Support of Claim (VA Form 21-4138)
33 fields, 2 pages
21-0966
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or D.I.C. (VA Form 21-0966)
49 fields, 2 pages
Who uses VA Form 21-4142?
The form and VA's page describe these uses.
Official sources and the blank
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Questions about Form 21-4142
Can I submit VA Form 21-4142 online?
Yes. VA's form page says you can submit your authorization online instead of sending the paper form. You can also fill out the PDF here free and print or download it.
Is this form needed for VA medical records?
No. The form says it is not needed to request VA medical records. It also says there is no need to fill it out if you already provided the private records or intend to get them yourself, and that doing so lengthens claim processing time.
What is the difference between VA Form 21-4142 and VA Form 21-4142a?
VA Form 21-4142 is the authorization to release records. VA Form 21-4142a, attached in the same PDF, names each provider or facility, the conditions treated and the dates of treatment.
How long is the authorization valid?
The form says it is good for 12 months from the date signed and expires automatically after 12 months if it is not revoked.
Can I limit what is released?
Item 12 is for limiting consent. The form says that if that space is left blank, there is no limitation to records.
Can I revoke the authorization?
The form says it can be revoked in writing at any time, except where a source has already relied on it. The statement goes to the VA Regional Office handling the claim, or the Board of Veterans' Appeals for an appeal, with a copy to each source.
Does VA pay fees for the records?
The form quotes 38 C.F.R. §3.159(c): "VA will not pay any fees charged by a custodian to provide records requested."
Where do I mail VA Form 21-4142?
For compensation claims the form lists Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444. It lists the Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365, for pension and survivors claims.