VA Form 21-4142a: General Release for Medical Provider Information to the Department of Veterans Affairs (VA)

What VA Form 21-4142a is for

This form names the private providers, the conditions they treated, the treatment dates and the records addresses so VA can request your private treatment records. It has no signature line: the signed permission is on VA Form 21-4142, so send the two together.

The 21-4142 download already includes these provider pages after the consent form. If you still need the signed consent, fill both in one PDF. Fill 21-4142 and 21-4142a together.

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
• Items 7 and 8: the patient's Social Security number and VA file number
• Treatment dates you left blank

Where to send it

• Send it with a signed VA Form 21-4142. This form has no signature line, and VA needs the signed consent to request the records.
• Online: VA's form page links to its online release-of-information application, which lets you ask VA to request records online.
• By mail, as printed on the form: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
• Pension or survivor benefit claims: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.
• Keep a copy, and track which records VA requested and which it actually 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

• VA's page for Form 21-4142a on VA.gov
• VA Form 21-4142 example and how to fill it out

This filler uses the August 2024 edition of the form.