The following information about this VA form comes from the VA forms database, and any changes are updated here nightly. Contact the form administration for further information.
Link to form
http://www.vba.va.gov/pubs/forms/VBA-21-4142a-ARE.pdf
Form number
21-4142a
Row ID
5354
Form title
General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (Fillable)
Issue date
Revision date
Form administration
VBA
Number of pages
2
Deleted
False
Form name
General Release for Medical Provider Information to the Department of Veterans Affairs
Form Language
English
Related to
Benefits
VA disability compensation
VA health care
When to use

Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.

Related forms
About VA Form 21-4142
Helpful links
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How to file a VA disability claim
Find out how to file a claim for disability compensation or increased disability compensation.