Short answer: VA Form 21-4142 is your signed permission for VA to request private (non-VA) treatment records, and VA Form 21-4142a is the list of providers, conditions, treatment dates and addresses VA should contact. Both current editions are dated August 2024. Get them from VA: the 21-4142 PDF (it includes a copy of 21-4142a), the standalone 21-4142a PDF, or VA's online authorization. Below is every item on both forms, in order, with two fictional filled-in examples.

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 again on November 8, 2026 through VA's 21-4142 page and 21-4142a page, and both pages still list August 2024 as the form revision date. The 21-4142 download includes the companion provider form after its own instructions. The standalone 21-4142a is also available.

How 21-4142 and 21-4142a work together

VA's regulation on private records explains why there are two forms. When VA tries to get records from a private doctor, you must give enough information to identify and locate them (the custodian, the approximate time frame, and for medical records, the condition treated), and, if necessary, authorize their release in a form the record holder accepts. That is 38 C.F.R. 3.159(c)(1)(i) and (ii). The 21-4142a supplies the first part. The signed 21-4142 supplies the second.

VA Form 21-4142VA Form 21-4142a
Official nameAuthorization to Disclose Information to the Department of Veterans Affairs (VA)General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
What it doesGives consent: which kinds of sources may release, what may be released, to whom, for what purpose, and for how longNames the specific providers, the conditions each one treated, the treatment dates, and the address
Items1 to 161 to 13, with five provider groups (9 to 13), each with fields A to D
SignatureItem 13 (required), dated in Item 14 (required)None. It relies on the signed 21-4142
Mailing instruction printed on the formPage 3 lists compensation, pension and survivors, fiduciary, and Board addressesIts instructions say to mail it to the Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444

A provider sheet without a signed authorization gives VA names but no consent; an authorization without a provider sheet gives VA consent but no one to contact. Send them together.

If you file VA Form 21-526EZ online, you may not need either paper form. VA's 21-526EZ page says the online application asks whether you give permission to get records from non-VA providers, and that if you provide this information while filling out the form online, you do not need to submit separate supporting forms.

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, in capital letters, that filling it out anyway "will lengthen your claim processing time."

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. If you need your VA records for your own review, the VA medical records guide covers Blue Button downloads, full-copy requests, your C-file, and service treatment records.

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.

Upload the records yourself, or ask VA to request them?

Beyond the form's own warning above, here is what VA says:

  • VA's how to file page: VA encourages you to send all your supporting documents with your claim and says this will help it process the claim quickly.
  • VA's Fully Developed Claims page: to have a claim treated as fully developed, you submit all private medical records related to the claimed condition with the claim. VA describes this as the way to get a faster decision.
  • Page 3 of 21-4142: VA recommends sending correspondence electronically, calling it the fastest method of receipt.

None of these sources gives a number of days saved, so I do not give one either.

Asking VA still makes sense when a provider will not release records to you, when you cannot get them before you file, or when you do not know what the provider holds. When VA makes the request:

  • VA makes reasonable efforts, which generally means an initial request and, if the records do not arrive, at least one follow-up request (38 C.F.R. 3.159(c)(1)).
  • VA will not pay a records custodian's fees. Both the form and the regulation say so.
  • If VA cannot get the records, it must tell you which records it could not obtain, what it tried, and what it will do next (38 C.F.R. 3.159(e)).
  • The 21-526EZ instructions add that it is your responsibility to make sure VA receives requested records that are not held by a federal agency.

A middle path is to upload what you already have and use 21-4142 only for the providers you cannot reach yourself. Before you upload a large record set, Raven Scan reads medical records, including a VA Blue Button report, and finds the evidence by condition, so you can see what your records already cover before you decide what VA still needs to request. Claim Raven sells this tool.

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

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

  • 1: Name (first, middle initial, last).
  • 2: Social Security number.
  • 3: VA file number, if applicable.
  • 4: Birth date, in MM/DD/YYYY format.
  • 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.

Page 2 repeats a box at the top for the veteran's Social Security number. Fill it in so the pages stay matched if they are separated. The form also says you may complete it online or by hand; by hand, print in ink with one letter per box.

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. The printed list is broad: all medical sources (hospitals, clinics, labs, physicians, psychologists, and others, including mental health, correctional, addiction treatment, and VA health care facilities), social workers and rehabilitation counselors, consulting examiners used by VA, employers, insurance companies, workers' compensation programs, and others who may know about your condition, such as family, neighbors, friends, and public officials.

Section IV describes the information that may be released, including medical history, functional limitations, and information about ability to work. It names specific permission for records about mental impairments, substance use, sickle cell anemia, communicable and non-communicable diseases including HIV/AIDS tests and records, and gene-related impairments including genetic test results.

The authorization includes sensitive categories described on the form. Its mental-health language excludes psychotherapy notes as defined in the cited federal privacy rule (45 C.F.R. 164.501). 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 (currently 8/31/2027). 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.

What the limitation in Item 12 actually does

The form's exact label reads: "If my consent to this information is limited, the limitation is written here (If this space is left blank, there is no limitation to records)."

So the field does one thing: it lets you narrow what you are consenting to release. Left blank, your consent covers everything Section IV describes, from the kinds of sources Section III lists. A limit might name a date range, a condition, or a type of record.

The form does not say that a limitation cancels the release, and I have found no VA source that says so. It also does not explain how VA or a provider applies a limit. VA's private provider page says that authorizing release of "all medical records" is permissible, so an unlimited authorization is a normal choice.

The practical risk is a mismatch. If your 21-4142a lists treatment from 2022 to 2026 but Item 12 limits consent to records from 2025 onward, the earlier records you asked for fall outside your own consent. If you write a limit, check it against every date and condition on the provider sheet before you sign.

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 you are being treated for by that provider.
  • C: Treatment period, from and to, in MM/DD/YYYY format.
  • D: Complete provider or facility street address, including city, state, ZIP code, and country.

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 form does not say what to do with a sixth provider. If you have more than five, ask VA at 800-827-1000 or an accredited representative how to list the rest rather than squeezing two providers into one group.

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.

Second fictional example: A private counselor, a primary care office, and a date limit

Dana Ellis is invented. So is every provider and date below. Dana is claiming an anxiety condition and wants VA to request records from a private counselor and a primary care office. Dana already downloaded an urgent care visit from November 2022 through a patient portal and will upload it directly. Because the claim includes a mental health condition, Dana also completes VA Form 21-0781, which is a separate form (see the 21-0781 walkthrough).

On 21-4142:

ItemDana's fictional entry
1Dana R. Ellis
2[Dana's Social Security number]
3Blank, because Dana has no VA file number yet
4[Dana's birth date, MM/DD/YYYY]
5[Service number, if Dana has one]
6 and 7[Dana's mailing address and phone number]
8Email entered; electronic correspondence box checked
9 to 11Blank, because Dana is the patient
12Records dated 01/01/2023 to present only.
13 and 14Dana signs and enters the actual signing date
15Dana R. Ellis
16Blank, because Dana is signing for Dana

On 21-4142a:

ItemDana's fictional entry
1 to 5The same identifiers as Items 1 to 5 on 21-4142
6 to 8Blank
9A[Counseling practice's actual name]
9BAnxiety and sleep problems
9CFrom 03/14/2023 to 10/02/2026
9D[Counseling practice's verified records address]
10A[Primary care practice's actual name]
10BAnxiety medication management
10CFrom 01/09/2023 to 09/18/2026
10D[Primary care practice's verified records address]

Three things make this pair consistent. First, every date on the provider sheet starts after the 01/01/2023 limit in Item 12, so the limit does not cut off anything Dana asked VA to get. Second, the November 2022 urgent care visit falls before that limit, which is fine because Dana is uploading it instead of asking VA for it. Third, the counselor's treatment records are within the authorization's scope, but psychotherapy notes as defined in 45 C.F.R. 164.501 are excluded by the form's own wording, so Dana should not expect them in the response.

Where to send the pair

Online authorization: Both official form pages link to VA's online authorization, which VA offers instead of the paper form. 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 VA claim status guide explains why a claim can move back to evidence gathering while VA waits on 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.

Keep your own list of what you asked VA to request and what VA has received, and update it when VA sends a letter.

VA Form 21-4142 questions

What is the difference between VA Form 21-4142 and 21-4142a?

21-4142 is the signed authorization that lets VA obtain your records from private sources. 21-4142a names the providers, the conditions each one treated, the treatment dates, and the addresses. When you want VA to request private records, you send both, and the signature goes on 21-4142, Item 13.

Do I need VA Form 21-4142 if I already have my records?

Not for those records. The form says you do not need the release for records you already submitted or will obtain and submit yourself, and it warns that an unnecessary release can lengthen processing.

How long is VA Form 21-4142 valid?

The authorization lasts 12 months from the signing date in Item 14 unless you revoke it in writing sooner. That period is separate from the OMB expiration date printed at the top of the PDF, which concerns the form's paperwork approval, not your consent.

Does VA Form 21-4142 cover mental health records?

Its mental-health language excludes psychotherapy notes as defined in the cited federal privacy rule. That does not exclude all mental-health treatment records, so read the actual scope before you sign.

Do I need VA Form 21-4142 for VA medical records?

No. The form says the release is not needed to request VA medical records.

Where do I sign VA Form 21-4142a?

The current 21-4142a has no separate signature line. The signed authorization is on 21-4142, Item 13, with the date in Item 14. Send the signed 21-4142 with the provider sheet.

Where do I download the VA Form 21-4142a PDF?

VA's 21-4142a page links the standalone PDF, August 2024 edition. The 21-4142 PDF also contains a copy of 21-4142a after its own instructions, so one download gets you both.

Can I submit VA Form 21-4142 online?

Yes. Both VA form pages link to an online authorization you can use instead of the paper form. If you are filing VA Form 21-526EZ online, VA says the application itself asks for this permission, and answering there means you do not need to submit the separate forms.

Is VA Form 21-4142 the VA medical release form?

It is VA's release for records from non-VA sources, such as a private doctor or hospital. The form says it is not needed to request VA medical records. For your own copies of VA records, use Blue Button or a records request instead; the VA medical records guide explains both.

Sources and scope

Verified November 8, 2026: the August 2024 editions of both forms (VA's form pages still list August 2024 as the revision date, and each PDF says it supersedes the July 2021 edition), VA's 21-4142 and 21-4142a form pages, the linked online authorization, VA's 21-526EZ form page, VA's how to file and Fully Developed Claims pages, VA's evidence-upload guidance, VA's private provider page, the 21-526EZ instructions, the intake directory in the 20-0995 PDF, and 38 C.F.R. 3.159 on eCFR. First verified September 25, 2026. The walkthrough follows the numbered paper forms. Both examples are 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. Free help is available from accredited Veterans Service Organizations; find a VSO.