Section I: Veteran's identification
Items 1 to 5 ask for the Veteran's name, Social Security number, VA file number, date of birth and service number if applicable.
21-4142a
General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA form 21-4142a)
- Agency
- VA
- Revision
- August 2024
- Fillable fields
- 96
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-4142a: General Release for Medical Provider Information to VA
VA Form 21-4142a is the U.S. Department of Veterans Affairs General Release for Medical Provider Information to the Department of Veterans Affairs (VA). VA's form page says to use it to give VA permission to get medical provider information from a non-VA source like a private doctor or hospital, such as the name and address of a facility and your medical treatment dates.
The form's instructions say to use it to provide the name of the provider or facility you have received treatment from to VA. It has room for five providers or facilities, each with the conditions treated, the dates of treatment and the street address. VA's page lists VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs, as the related form.
The form is two pages. VA's page says you can submit your authorization online instead of sending 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 21-4142a
Section II: patient, if other than the Veteran
Items 6 to 8 identify the patient whose records VA is requesting: name, Social Security number and VA file number.
Section III: medical provider information
Items 9 to 13 each hold one provider or facility name, the conditions you are being treated for, the dates of treatment from and to, and the provider or facility street address.
Privacy Act and burden notices
The form says to read these on page 2 before completing it. They say the obligation to respond is voluntary and estimate a respondent burden of 5 minutes.
Penalty statement
Page 2 ends with the penalty for the willful submission of any statement or evidence of a material fact knowing it to be false.
How to complete VA Form 21-4142a
- 1
Read page 2 first
The instructions say to read the Privacy Act and Respondent Burden on page 2 before completing the form.
- 2
Fill in Sections I and II
Enter the Veteran's details, and the patient's details if the records are for someone else. By hand, the form asks for ink, neat and legible printing and one letter per box.
- 3
List each provider or facility
Use one block in Section III per provider or facility, with the conditions treated, the treatment dates and the address.
- 4
Mail it or submit online
Mail the form to the Evidence Intake Center in Janesville, Wisconsin, or submit the authorization online through VA's form page.
Why fill Form 21-4142a 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 getting help
By mail
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Online
VA's form page says you can submit your authorization online instead of sending the paper form.
Questions
The form points to https://ask.va.gov and the toll-free number 1-800-827-1000. For TDD, the Federal relay number is 711.
Edition
The August 2024 edition supersedes the July 2021 edition. It carries OMB Control No. 2900-0858, which expires 8/31/2027.
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Who uses VA Form 21-4142a?
VA's form page and the form describe these uses.
Official sources and the blank
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Questions about Form 21-4142a
What is VA Form 21-4142a used for?
VA's form page says to use it to give VA permission to get medical provider information from a non-VA source like a private doctor or hospital, such as the facility's name and address and your treatment dates.
How is VA Form 21-4142a related to VA Form 21-4142?
VA's page for 21-4142a lists VA Form 21-4142 as its related form. VA describes 21-4142 as the form that gives VA permission to obtain your personal information from a non-VA source.
How many providers can I list?
Section III has five blocks, Items 9 to 13, each for one provider or facility.
Can the records be for someone other than the Veteran?
Section II is for the patient's identification when the records VA is requesting are for someone other than the Veteran.
Can I submit it online?
Yes. VA's form page says you can submit your authorization online instead of sending the paper form.
Where do I mail VA Form 21-4142a?
The form says to mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.