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VA Form 21-4142a: General Release for Medical Provider Information to the Department of Veterans Affairs

VA Form 21-4142a lists the private medical providers VA should contact for your records. It works together with the signed authorization on VA Form 21-4142.

Fill out VA Form 21-4142a in the editor Download the blank PDF Quick fill on this page

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What is VA Form 21-4142a?

VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs, collects the details VA needs to actually request private treatment records: each provider or facility's name and address, the conditions treated, and the approximate dates of treatment. VA uses this list to send records requests to the right places.

On its own the form is just a list; the legal permission comes from VA Form 21-4142, so the two are normally submitted together. The current edition is dated August 2024, and the two page form has room for several providers, with additional copies allowed if you have more.

Who files VA Form 21-4142a?

Veterans identifying private doctors, hospitals, and clinics that hold records relevant to a claim
Survivors and dependents whose claims rely on non-VA treatment records
Claimants responding to a VA request to identify treatment sources
Representatives helping a claimant document where treatment occurred

How to fill out VA Form 21-4142a

Fill in the claimant's name, Social Security number, and VA file number at the top.
For each provider or facility, enter the name, full mailing address, the condition treated, and the approximate dates of treatment.
Use additional copies of the provider section if you have more sources than the form holds.
Sign and date the form, and complete the signed authorization on VA Form 21-4142 to go with it.
Submit both with your claim through va.gov, or mail them to the VA Claims Intake Center address in the instructions.

Quick fill VA Form 21-4142a on this page

Prefer to see the form itself while you type? Open VA Form 21-4142a in the editor to fill it on the actual pages, add a signature, and download.

These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 1 48 fields

Read Instructions above. SECTION 1 - VETERAN'S IDENTIFICATION INFORMATION. Read Note above. 1. VETERAN'S NAME (First, Middle Initial,

1. VETERAN'S NAME. Enter Middle Initial. 1 character max.

1. VETERAN'S NAME. Enter Last Name. 18 characters max.

2. SOCIAL SECURITY NUMBER. Enter First Three Digits.

2. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

2. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

3. V. A. FILE NUMBER. Enter 9 digit file number.

4. DATE OF BIRTH. Enter 2 digit Month.

4. DATE OF BIRTH. Enter 2 digit day.

4. DATE OF BIRTH. Enter 4 digit year.

5. VETERAN'S SERVICE NUMBER (If applicable). 9 characters max.

SECTION 2 - PATIENT IDENTIFICATION FOR RECORDS V. A. IS REQUESTING (If other than veteran). 6. PATIENT'S NAME (First, Middle Initial,

6. PATIENT'S NAME. Enter Middle Initial. 1 character max.

6. PATIENT'S NAME. Enter Last Name. 18 characters max.

7. SOCIAL SECURITY NUMBER. Enter First Three Digits.

7. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

7. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

8. V. A. FILE NUMBER. Enter 9 digit file number.

SECTION 3 - MEDICAL PROVIDER INFORMATION. 9. A. PROVIDER OR FACILITY NAME.

9. B. CONDITIONS YOU ARE BEING TREATED FOR.

9. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 9. A.). FROM DATE. Enter 2 digit

9. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

9. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

9. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

9. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

9. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

9. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

9. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

9. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

10. A. PROVIDER OR FACILITY NAME.

10. B. CONDITIONS YOU ARE BEING TREATED FOR.

10. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 10. A.). FROM DATE. Enter 2 digit

10. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

10. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

10. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

10. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

10. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

10. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

10. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

10. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

Page 2 45 fields

11. A. PROVIDER OR FACILITY NAME.

11. B. CONDITIONS YOU ARE BEING TREATED FOR.

11. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 11. A.). FROM DATE. Enter 2 digit

11. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

11. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

11. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

11. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

11. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

11. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

11. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

11. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

12. A. PROVIDER OR FACILITY NAME.

12. B. CONDITIONS YOU ARE BEING TREATED FOR.

12. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 12. A.). FROM DATE. Enter 2 digit

12. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

12. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

12. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

12. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

12. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

12. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

12. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

12. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

13. A. PROVIDER OR FACILITY NAME.

13. B. CONDITIONS YOU ARE BEING TREATED FOR.

13. C. DATE(S) OF TREATMENT. (Include the time period for the treatment by the provider listed in Item 13. A.). FROM DATE. Enter 2 digit

13. C. DATE(S) OF TREATMENT. FROM DATE. Enter 2 digit day.

13. C. DATE(S) OF TREATMENT. FROM DATE. Enter 4 digit year.

13. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit Month.

13. C. DATE(S) OF TREATMENT. TO DATE. Enter 2 digit day.

13. C. DATE(S) OF TREATMENT. TO DATE. Enter 4 digit year.

13. D. PROVIDER / FACILITY STREET ADDRESS (Number and street, P.O. or rural route). Number and Street. 30 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. Apartment or Unit Number. 5 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. City. 18 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. State or Province. 2 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. Country. 2 characters max.

13. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter first 5 digits.

13. D. PROVIDER / FACILITY STREET ADDRESS. ZIP or Postal Code. Enter last 4 digits.

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Frequently asked questions

What if I do not remember exact treatment dates?

Give your best estimate, such as a month and year or a range like "2019 to 2021". Approximate dates are acceptable and are usually enough for the provider to locate the records.

Do I send this form to my doctors myself?

No. Submit it to VA with your claim and the signed 21-4142 authorization. VA contacts the providers you listed and requests the records directly.

VA Form 21-4142a: General Release for Medical Provider Information to the Department of Veterans Affairs

What is VA Form 21-4142a?

Who files VA Form 21-4142a?

How to fill out VA Form 21-4142a

Quick fill VA Form 21-4142a on this page

Frequently asked questions

Related forms

VA Form 21-4142: Authorization to Disclose Information to the Department of Veterans Affairs

VA Form 21-526EZ, Application for Disability Compensation

VA Form 10-5345: Request for and Authorization to Release Health Information