VA Form 21-4142A: Download PDF & How to Fill Out (2025) – VA Form 21-4142A: General Release for Medical Provider Information to the Department of Veterans Affairs is a key document for U.S. veterans seeking disability benefits or other VA claims that require non-VA medical records.
What Is VA Form 21-4142A?
VA Form 21-4142A, titled General Release for Medical Provider Information to the Department of Veterans Affairs, serves as a supplemental form that lists your private (non-VA) medical providers, facilities, treatment dates, and conditions treated.
It works together with VA Form 21-4142 (Authorization to Disclose Information to the VA). The 21-4142 provides the general authorization (HIPAA-compliant consent), while the 21-4142A supplies the specific provider details so the VA knows exactly where to request records.
- Latest Revision: August 2024 (supersedes July 2021 version).
- OMB Control No.: 2900-0858 (expires August 31, 2027)
- Estimated Completion Time: About 5 minutes.
Official Download: Download VA Form 21-4142A (PDF) from VA.gov.
Why Veterans Need VA Form 21-4142A?
The VA requires private medical evidence to support disability compensation claims, pension applications, or other benefits. Without proper authorization and provider details, the VA cannot easily obtain records from civilian doctors, hospitals, or clinics.
This form helps:
- Streamline the claims process for a Fully Developed Claim (FDC).
- Ensure the VA receives treatment notes, diagnoses, test results, and hospitalization records from non-VA sources.
- Support service-connected disability ratings by providing comprehensive medical history.
When to Use VA Form 21-4142A?
Use this form whenever you have received medical care from:
- Private physicians or specialists
- Non-VA hospitals or clinics
- Community care providers (if not already in VA systems)
It is especially important for:
- New or supplemental claims
- Claims involving mental health, PTSD, chronic conditions, or injuries treated outside the VA system.
Note: You do not need this form for VA medical records, which the VA can access internally.
How to Fill Out VA Form 21-4142A Step-by-Step
- Section I – Veteran’s Identification Information
Provide your full name, Social Security Number, VA file number, date of birth, and service number (if applicable). - Section II – Patient Identification (if different from veteran, e.g., for a dependent).
- Section III – Medical Provider Information
For each provider/facility (up to 5 per form):- Provider or Facility Name
- Conditions treated for
- Dates of treatment (approximate ranges are acceptable, e.g., MM/DD/YYYY From: To:)
- Full street address, city, state, ZIP code, and country.
Tips for Accuracy:
- Print legibly or complete online if available.
- Use additional copies of the form for more than 5 providers.
- Include as many relevant providers as possible to strengthen your claim.
- Submit with a signed VA Form 21-4142.
VA Form 21-4142 vs. 21-4142A: Key Differences
| Form | Purpose | When Used |
|---|---|---|
| 21-4142 | General authorization/consent to release info | Required for every private provider |
| 21-4142A | Lists specific providers, addresses, dates | Supplemental list of all providers |
Both are typically submitted together.
How to Submit VA Form 21-4142A?
- Online (fastest): Use the VA’s online authorization tool.
- Mail: Send to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
- Upload with your claim via VA.gov or eBenefits.
- In person at a VA Regional Office or through a Veterans Service Officer (VSO).
You can submit these forms at any time during the claims process.
Tips for Veterans Filing with VA Form 21-4142A
- Gather provider contact information in advance.
- Provide specific treatment date ranges rather than vague descriptions.
- Keep copies of everything you submit.
- Consider working with an accredited VSO, claims agent, or attorney for complex claims.
- Track your claim status on VA.gov.
- If a provider charges fees or refuses, the VA will notify you.
Common Questions About VA Form 21-4142A
Do I need a new form for every claim?
It’s best to submit updated forms when adding new providers or for new claims.
Can I submit electronically?
Yes, online submission is encouraged and often processes faster.
What if I don’t remember exact dates?
Use your best approximation or a reasonable range.
Is this form HIPAA compliant?
Yes, when used with 21-4142, it meets federal privacy requirements.
For the most current instructions, always refer to the official form on VA.gov.
Get Help with Your VA Claim
If you need assistance completing or submitting VA Form 21-4142A, contact the VA at 1-800-827-1000 or visit VA.gov. Accredited representatives can provide free help.
Properly completing this form can significantly impact the speed and success of your VA disability claim. Download it today and ensure your private medical evidence is included.