VA Form 21-4142a
General Release for Medical Provider Information to the Department of Veterans Affairs
Who fills it
veteran
Journey phase
Evidence & Statements
Estimated time
15-30 minutes per batch of providers.
When to file
File with 21-4142. Required for any non-VA records request.
You filed VA Form 21-4142 (the authorization) and need to enumerate the specific providers and dates.
Gather before you start
—Provider name (doctor, hospital, clinic, lab, mental health provider, chiropractor)
—Complete street address with ZIP
—Approximate start date of treatment
—Approximate end date of treatment (or "ongoing")
—Phone number if known (helps VA contact provider for records)
Attach with the form
—VA Form 21-4142 (signed authorization) - REQUIRED companion
Section I - Veteran/Claimant Identification
Blocks 1-5Name, SSN, VA File Number, addressPII
Match exactly to your 21-4142.
Example
(use same as 21-4142)
Common mistakes
- Mismatched name/SSN with the 21-4142 - both forms reject as a pair.
Section II - Provider Information
Blocks 6-12Provider name, address, dates, phone (per provider)Repeatable
For each non-VA provider: full name, complete street address, approximate date range of treatment, and phone if known. Be as specific as possible. Vague entries delay records requests by weeks.
Example
e.g., Provider: Dr. Jane Smith, MD - Smith Orthopedic Group Address: 123 Main St, Suite 200, Phoenix AZ 85001 Dates: 03/15/2019 to present Phone: (602) 555-0100
Common mistakes
- Vague provider names ("my back doctor") - VA cannot send records request to "my back doctor."
- Wrong or incomplete address - records request gets returned to sender; weeks lost.
- Date ranges that exclude the period of evidence you need - "started seeing him in 2019" is fine; "approximately 2018-2024" is fine; "for years" is not.
- Forgetting to list a critical provider - VA only requests from providers on this list.
Authority
38 CFR 3.159 - Duty to notify, duty to assist, evidence development.
Section III - Signature
Block 13Signature and datePII
Sign and date in the same ink/electronic style as your 21-4142. Both forms must reach VA together as a signed pair, otherwise the records request cannot be initiated under HIPAA.
Example
(signature/date when filing)
Common mistakes
- Forgetting to sign - VA returns the package and weeks are lost waiting for re-submission.
- Signing 21-4142a but not signing the companion 21-4142 - both must be signed; mismatched signatures rejected at intake.
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.