U.S. DEPARTMENT OF VETERANS AFFAIRS

VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs

Give the VA permission to collect your private medical records to support your disability claim.

VA Form 21-4142 is the official authorization that lets the Department of Veterans Affairs request your medical records directly from private doctors, hospitals, and other non-VA sources. Without it, VA cannot obtain outside medical evidence for your disability or benefits claim.

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Average time

5–15 minutes

Difficulty

simple

Best for

Veterans filing or updating a VA disability claim who have private medical records VA needs to review

What this form stands for

Get VA the private medical evidence it needs to process your disability claim fully and accurately, so your claim is decided on the complete record.

This authorization expires 12 months after you sign it. If your claim is not resolved by then, VA may ask you to sign a new one. Also: revoking this authorization — or leaving it out — means VA cannot get your outside medical records, which can delay or deny your claim.

What you'll need

Veteran's full legal name, Social Security number, and date of birth
Veteran's current mailing address and phone number
Name, address, and treatment dates for each private doctor or facility VA should contact (up to 5 providers on companion form 21-4142a)
If someone other than the veteran is signing: that person's full name, title, organization, and address (plus docket number and court info for court-appointed representatives)

How the walkthrough is organized

Section I — Veteran Identification

Your full name, Social Security number, VA file number (if any), date of birth, service number (if pre-1974), mailing address, phone number, and optional email for VA correspondence.

Section II — Patient Identification

Only fill this section if the records VA will request belong to someone other than you (for example, you are a fiduciary acting for another person). Enter that person's name, SSN, and VA file number.

Section III & IV — Sources and Scope of Release

These sections are pre-filled on the form. You are authorizing VA to request records from all private medical sources — hospitals, clinics, mental health providers, substance abuse programs, employers, and others. Review this section so you understand what you are authorizing.

Section V — Authorization, Limitations, and Signature

Optionally limit what VA can release (Item 12), then sign and date the form (Items 13–14). Print your name (Item 15) and describe your relationship to the veteran (Item 16). The authorization expires 12 months from the date you sign.

Form 21-4142a — Provider List

The companion form included in the same PDF. List up to five specific providers or facilities — including the conditions treated and treatment date range — so VA knows exactly where to send records requests.

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