VA Form 21-4142
Authorization to Disclose Information to the Department of Veterans Affairs
Who fills it
veteran
Journey phase
Evidence & Statements
Estimated time
10-15 minutes (longer if you have many providers - file one 21-4142 + 21-4142a per provider OR consolidate).
When to file
File alongside 21-526EZ (or any time during claim development when you identify a private provider). Without this signed release, VA cannot legally request the records under HIPAA.
You have private (non-VA) treatment records that support your claim and you want VA to obtain them directly from the provider.
Gather before you start
—Your full legal name, SSN, VA File Number
—Names and addresses of every non-VA provider whose records you want VA to obtain
—Approximate date ranges of treatment with each provider
Attach with the form
—VA Form 21-4142a (the provider-list companion form) - REQUIRED with this release
Section I - Veteran/Claimant Identification
Blocks 1-5Name, SSN, VA File Number, addressPII
Match exactly to your 21-526EZ. VA cross-files this release to your active claim.
Example
(use same as 21-526EZ)
Common mistakes
- Mismatched name/SSN with the active claim - release fails to attach.
Section II - Authorization
Block 6Authorization scope
The pre-printed authorization language allows VA to request records from the providers listed on the companion 21-4142a. You are NOT signing a blanket release of your entire medical history - only what you list.
Example
(read pre-printed text carefully before signing)
Common mistakes
- Assuming the release covers VA-internal records too - VA already has those; this is for NON-VA providers only.
- Worrying about "blanket" disclosure - the scope is limited to providers you name on 21-4142a.
Authority
38 CFR 3.159 - Duty to notify, duty to assist, evidence development.
38 USC 5103A - VA duty to obtain federal records, develop nexus exams.
Section III - Expiration
Block 7Expiration date or event
You can specify a date the authorization expires, or leave it open. Most veterans leave it open during claim processing because development can take 12-18+ months. You can revoke at any time in writing.
Example
e.g., Open until claim decided, or specific date if you prefer
Common mistakes
- Setting a too-short expiration (e.g., 30 days) - claim development takes months; release expires before VA requests records.
- Forgetting that you can revoke at any time - you are not locked in.
Section IV - Signature
Blocks 8-9Signature and datePII
Sign and date. Without your wet signature (or VA.gov electronic signature), VA cannot legally request records under HIPAA.
Example
(signature/date when filing)
Common mistakes
- Forgetting to sign - VA cannot use unsigned releases. Most common reason 21-4142 packages get returned.
- Forgetting to also file 21-4142a - the release authorizes; the 4142a names the providers. Both required.
Statutory & regulatory authority
38 CFR 3.159 - Duty to notify, duty to assist, evidence development.
38 USC 5103A - VA duty to obtain federal records, develop nexus exams.