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.
What is 21-4142 used for?
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.
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.
Time, difficulty & who this form is for
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 do I need before I start?
- 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.
What happens after I complete it?
Answer the questions, review your document, then follow its official signing and delivery instructions. Downloading does not submit the form.
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