VA Form 21-4142
Authorization to Disclose Information to the Department of Veterans Affairs
You have private (non-VA) treatment records that support your claim and you want VA to obtain them directly from the provider.
- 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.
Official VA form page: https://www.va.gov/find-forms/about-form-21-4142/
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.
(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.
(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.
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.
(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 and 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.