VA Form 21-4142 (and 21-4142a)

Create Document

VA Form 21-4142 and Form 21-4142a are medical records release forms that a patient (veteran) must complete in order to release private health information to the Department of Veterans Affairs (VA). The document authorizes the release of all medical records from any private doctors or non-VA healthcare facilities for a period of 12 months from the signing date.

VA Form 21-4142 (and 21-4142a)

VA Form 21-4142 and Form 21-4142a are medical records release forms that a patient (veteran) must complete in order to release private health information to the Department of Veterans Affairs (VA). The document authorizes the release of all medical records from any private doctors or non-VA healthcare facilities for a period of 12 months from the signing date.

Create Document
PDF
PDF

Last updated April 23rd, 2024

Document Preview

VA Form 21-4142 and Form 21-4142a are medical records release forms that a patient (veteran) must complete in order to release private health information to the Department of Veterans Affairs (VA). The document authorizes the release of all medical records from any private doctors or non-VA healthcare facilities for a period of 12 months from the signing date.

Downloads: 118
  1. Home »
  2. HIPAA »
  3. Medical Records Release »
  4. Veterans »
  5. VA Form 21-4142

What is VA Form 21-4142 Used For?

Form 21-4142 is required when trying to access what is known as a veteran’s private medical evidence. This evidence, which consists of medical records from non-VA healthcare professionals, will be used by the Veterans Benefits Administration when assessing the veteran’s disability benefits claim or other compensation service.

VA Form 21-4142 and VA Form 21-4142a

While VA Form 21-4142 authorizes the Department to access a veteran’s non-VA treatment medical records, Form 21-4142a must be completed at the same time to disclose all medical providers or facilities that administered medical treatment to the veteran.

Veterans Affairs Form 21-4142 and Form 21-4142a are combined into one packet as they must be submitted jointly in order to obtain all necessary health care records from a non-VA physician or medical facility.