VA Form 21-4142a
General Release for Medical Provider Information to the Department of Veterans Affairs
You filed VA Form 21-4142 (the authorization) and need to enumerate the specific providers and dates.
- 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.
Official VA form page: https://www.va.gov/find-forms/about-form-21-4142a/
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.
(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.
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.
(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 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.