VA Form 21-4142 gives VA permission to obtain records. VA Form 21-4142a identifies the providers, conditions treated, treatment dates, and addresses. When you want VA to request private treatment records, the two forms do different parts of the same job.

Both current PDFs are dated August 2024, replacing July 2021. I checked them on September 25, 2026 through VA's 21-4142 page and 21-4142a page. The 21-4142 download includes the companion provider form after its own instructions. The standalone 21-4142a is also available.

Decide whether VA needs to request anything

The first page of 21-4142 gives a useful instruction: complete it when you want VA to obtain private treatment records on your behalf. If you already submitted those records, or intend to obtain and submit them yourself, you do not need this release for those records. The form warns that an unnecessary release can lengthen processing.

It also says the release is not needed to request VA medical records. Private care and VA records should not be treated as interchangeable just because both concern the same condition.

Before filling the form, make a short list:

  • Which relevant records do you already have?
  • Which records have you already sent to VA?
  • Which remaining provider should VA contact?
  • What name and address does that provider use for records requests?

This is an organizing step, not an extra VA form. It helps prevent a request for records that are already in the claim and a missed request for the records that are not.

Form 21-4142, Section I: Veteran information, Items 1 to 8

The 21-4142 PDF begins with the veteran's identifiers:

  • 1: Name.
  • 2: Social Security number.
  • 3: VA file number, if applicable.
  • 4: Birth date.
  • 5: Service number, if applicable.
  • 6: Complete mailing address.
  • 7: Telephone number, including the international field when applicable.
  • 8: Optional email, with a separate electronic-correspondence agreement.

Use the identifiers belonging to the veteran whose benefits record is involved. A clinic needs enough correct identifying information to match the request to the patient. A typo in a birth date can create a records problem even if the explanation of the condition is clear.

Section II: A patient other than the veteran, Items 9 to 11

Complete this section only if the patient whose records VA is requesting is someone other than the veteran.

9 asks for the patient's name, 10 their Social Security number, and 11 their VA file number, if applicable. Do not enter the helper or person who typed the form here unless that person is actually the patient whose records are sought.

This distinction can matter in survivor or dependent claims. The veteran, claimant, patient, and signer are not necessarily the same person. Read each field's label instead of repeating one identity throughout the document.

Sections III and IV: Read what you are authorizing

These are printed explanations, not boxes for listing your doctors. The provider list belongs on 21-4142a.

Section III identifies the sources covered by the authorization, including medical providers and other sources with relevant information. Section IV describes the information that may be released, including medical history, functional limitations, and information about ability to work.

The authorization includes sensitive categories described on the form. Its mental-health language excludes psychotherapy notes as defined in the cited federal privacy rule. That does not mean it excludes all mental-health treatment records. Read the actual scope rather than assuming the word psychiatric describes a separate blanket exclusion.

The form covers past information and information created within the stated 12-month period after signing. It also says VA will not pay a records custodian's fees. Giving consent therefore does not guarantee that every requested record will be obtained without further action.

12: Write any limitation on consent. Leaving this field blank means there is no limitation under this item. If you want a restriction, identify it clearly enough that VA and the records holder can understand it. Do not expect a note elsewhere to silently narrow this field.

13: Signature of the person authorizing disclosure. 14: Actual signing date. Both are required.

15: Printed name of the person signing. 16: Relationship to the veteran or claimant when signing for someone else, with the additional identifying and authority information requested. Court appointments require the docket number, county, and state. A relative should not treat kinship as a substitute for the authority the form requires.

The authorization lasts 12 months from the signing date in Item 14 unless revoked sooner. Do not confuse that period with the OMB expiration date printed at the top of the PDF. One concerns your authorization; the other concerns the form's paperwork approval.

The patient acknowledgment explains written revocation. Send it to the VA office handling the claim, or the Board if applicable, and directly to the sources you no longer want to disclose information. Revocation does not undo disclosures already made or prevent VA from using information already received as the form explains.

Form 21-4142a, Sections I and II: Match the records to the patient

On the standalone 21-4142a PDF, 1 through 5 ask for the veteran's name, Social Security number, VA file number, birth date, and service number if applicable.

6 through 8 identify the patient, Social Security number, and VA file number when the patient is someone other than the veteran. These correspond to the same patient distinction on 21-4142, but the item numbers differ. Do not transfer entries by number alone.

Check that the two forms refer to the same veteran and intended patient. The companion form cannot correct a consent signed for the wrong person.

Section III: Providers, Items 9 to 13

There are five provider groups: 9, 10, 11, 12, and 13. Every group uses the same lettered fields:

  • A: Provider or facility name.
  • B: Conditions treated by that provider.
  • C: Treatment period, from and to, using the requested date format.
  • D: Complete provider or facility street address.

Put one provider entry in each group you use. A hospital and a separate private specialist may hold different records even if the treatment occurred during the same month.

Use the name of the records holder, not just a clinician's first name or a description such as my back doctor. Check the mailing address for records requests. The building where you had an appointment may be different from the office that releases records.

For treatment dates, use appointment records or a patient portal where possible. Do not invent exact dates to make the boxes look complete. If something is uncertain, identify the uncertainty in an accompanying explanation and ask VA how to handle missing information if necessary.

The current 21-4142a has no separate signature line. The signed authorization is on 21-4142, Item 13. Sending a detailed provider sheet without the needed signed consent leaves VA with names but not the authorization this process calls for.

Fictional example: Two private sources and one record already supplied

This is an invented record-request exercise. The provider labels are placeholders, not real clinics, and no patient identifiers are included.

Assume a veteran wants VA to obtain orthopedic records from February 6, 2024 through September 4, 2026 and physical-therapy records from May 1 through July 31, 2026. The veteran already uploaded a separate imaging report.

On 21-4142, the veteran enters the requested identifying information, reads the consent, completes Item 12 if a limitation is intended, and signs and dates Items 13 and 14. The example does not select a consent scope for the reader.

On 21-4142a:

  • 9A: [Orthopedic practice's actual name].
  • 9B: Right knee condition.
  • 9C: 02/06/2024 to 09/04/2026.
  • 9D: [Practice's verified records address].
  • 10A: [Physical-therapy practice's actual name].
  • 10B: Right knee rehabilitation.
  • 10C: 05/01/2026 to 07/31/2026.
  • 10D: [Therapy practice's verified records address].

The already-submitted imaging report is noted on the veteran's own tracking list. If no additional records are needed from that imaging provider, the veteran does not add an unnecessary request merely to use another blank row.

Where to send the pair

Online authorization: Both official form pages link to VA's release-information application. Use that process when asking VA to request records online.

Upload: The 21-4142 instructions also point to VA's evidence upload guidance and AccessVA for electronic correspondence. Choose the route matching the pending claim or review.

Mail for compensation: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

Mail for pension or survivor benefits: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365. Page 3 of 21-4142 also provides separate fiduciary and Board addresses; use the address for your actual proceeding.

Fax: Neither form prints a dedicated fax line. VA's benefit intake directory lists 844-531-7818 for compensation and 844-655-1604 for pension and survivors. These are general routes. Follow your VA letter or confirm routing at 800-827-1000, particularly for a Board matter.

What happens after, and what commonly goes wrong?

VA uses the authorization and provider details to request records. Submission of the forms is not proof that the clinic has sent them or that VA received every page. Keep your copy and confirmation, watch for requests from VA, and distinguish requested records from received records.

The preventable problems are a missing signature or date, an expired authorization, inconsistent patient identifiers, an incomplete address, or treatment dates that omit the period you wanted. Also check that a consent limitation is consistent with the records you are asking VA to obtain.

If you already have the records, follow the appropriate evidence-upload process instead of asking VA to obtain the same set again. The Supplemental Claim walkthrough explains how identifying records fits that particular review form.

Claim Raven's Evidence Checklists can keep notes about a condition's records and what remains to gather. Use a note to distinguish requested from received. A checked item tracks your progress; the tool does not inspect the document or decide whether the evidence is sufficient.

Sources and scope

Verified September 25, 2026: both August 2024 PDFs, their VA form pages, the linked online authorization route, VA's evidence-upload guidance, and the intake directory. The walkthrough follows the numbered paper forms. The example is fictional, and the provider placeholders must never be submitted as real information.

Where to go next

Disclaimer

I'm Landon, founder of Claim Raven and a U.S. Army veteran, not a lawyer, VSO, or VA-accredited representative. Claim Raven is data analysis, not legal, medical, or VA-accredited advice. Read the authorization before signing, use your own records, and ask an accredited representative about claim-specific evidence questions.