VA Form 21-4142: Authorization to Disclose Information to the Department of Veterans Affairs (VA)

Fill out VA Form 21-4142 online by answering plain-English questions. Claim Raven puts your answers on the official August 2024 edition of the form, and you download the filled PDF ready to sign. It is free with a Claim Raven account.

What VA Form 21-4142 is for

Use this form when you want VA to request private treatment records for you. If you already sent those records, or will get them yourself, you do not need it, and the form warns that an unneeded release can lengthen your claim. It is not needed for VA medical records. This download also includes Form 21-4142a, where you list the providers, with both forms filled in.

What you fill in by hand

The filler never asks for your Social Security number, VA file number, date of birth or signature. You write those in by hand. Leave these boxes for yourself:

  • Item 2: veteran's Social Security number (and the copy at the top of page 2)
  • Item 3: VA file number
  • Item 4: date of birth
  • Item 5: service number
  • International phone number
  • Items 10 and 11: the patient's Social Security number and VA file number
  • Items 13 and 14: signature and date signed
  • Form 21-4142a pages: items 2 to 5, 7 and 8, and the Social Security number at the top of its second page
  • Treatment dates you left blank

Where to send it

  • Sign and date items 13 and 14 first. Send the consent pages and the 21-4142a provider pages together.
  • Online: VA's form page links to its online release-of-information application. Use it if you want to ask VA to request the records online.
  • Upload: page 3 of the form points to va.gov/disability/upload-supporting-evidence and to Direct Upload at access.va.gov.
  • Compensation claims by mail: Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.
  • Pension and survivors benefit claims by mail: Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. Page 3 also lists fiduciary and Board of Veterans' Appeals addresses; use the one for your case.
  • Keep a copy. Sending the forms does not mean the provider sent the records, so track what VA requested and what it received.

Claim Raven does not submit forms to VA. You review the filled PDF, sign and date it, and send it to VA yourself. Claim Raven is independent and is not affiliated with VA.

Official form and guide

This filler uses the August 2024 edition of the form.