VA Form 21-4142 is a document used by the Department of Veterans Affairs and is commonly known as an Authorization and Consent to Release Information. This is a document that requires a veteran to provide his or her consent so that the VA may obtain the necessary information regarding their medical history and any treatments they may have received. VA Form 21-4142 is a fairly straightforward form, requiring the veteran’s name, social security number, and VA file number. In addition, the veteran will need to list the sources where the VA can find pertinent information, as well as the dates that medical treatments occurred. Once this form is completed and submitted, the VA can then make a decision on benefits that the veteran will be eligible for.
This form will be used by the United States Department of Veterans Affairs and Veterans Benefits Administration. The VA Form 21-4142 is known as an Authorization and Consent to Release Information to the Department of Veterans Affairs (VA). The form must be completed in order for the VA to obtain information regarding your medical treatments and history. This information will be needed in order to determine your eligibility for VA benefits.
The form is fairly simple to complete and only requires some basic information. The filer will need to include their identifying information, such as full name, social security number, and VA file number. The claimant will then need to list the sources where the VA can find the pertinent information. They can also detail the dates for the treatments to make the information easier to find.Â
This form is commonly used by veterans to authorize your health care providers to disclose and release all medical records to the VA.
A VA Form 21-4142 contains the following sections:
To complete a VA Form 21-4142, you need to provide the following information:
The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (example: civil or criminal law enforcement, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, and the administration of VA programs and delivery of VA benefits) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. The VA uses your SSN to identify your claim file. Â Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975 and still in effect.
The VA needs this information and your written authorization to obtain your treatment records to help us get the information required to process your claim. Title 38, United States Code, allows us to ask for this information. You can provide this authorization by signing VA Form 21-4142. Â It should take an average of 5 minutes to complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. OMB Control No. 2900-0858. Â Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. You may call toll free at 1-800-827-1000 to get information on where to send comments or suggestions about this form. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
Authorizes the release of any information that may have been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will use this information to determine eligibility for veterans benefits. Indicates understanding that the source being asked to provide the Veterans Benefits Administration with records under this authorization may not require the execution of this authorization before it provides treatment, payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. Understanding that once the information is sent to the VA, the information will no longer be protected by the HIPAA Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a. Understanding authorization may be revoked in writing at any time except to the extent a source of information has already relied on it to take action. Â
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You can obtain additional copies of the form at WWW.VA.GOV/VAFORMS. Â If you need additional information about VA Form 21-4142, you should visit https://www.benefits.va.gov/privateproviders/.
