VA Form 21-4142a, the General Release for Medical Provider Information to the Department of Veterans Affairs (VA), is the form you use to give VA the name and address of a provider or facility that has treated you. Searches for 21-4142a usually come from veterans who are working on a disability claim and need to list private doctors or hospitals. On FillingPDF you can fill out the form online and download or print the completed PDF; the VA publishes the original at www.va.gov/vaforms, and the completed form is mailed to the VA Evidence Intake Center.
Last updated
What is 21-4142a?
VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), is the Veterans Benefits Administration form on which you identify the providers or facilities that treated you, so VA can obtain that information from a non-VA source such as a private doctor or hospital.
The VA's page for the form says it gives VA permission to gather information such as the name and address of a facility and your medical treatment dates. The form collects exactly that: the veteran's identification (items 1 to 5), the patient's identification when the records VA is requesting belong to someone other than the veteran (items 6 to 8), and up to five providers or facilities (items 9 to 13), each with its name, the conditions treated, the treatment dates and the street address.
Do not confuse it with VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA). The VA describes that companion form as the one that gives VA permission to obtain your personal information from a non-VA source, such as your medical treatment, hospitalizations, psychotherapy or outpatient care.
This is the August 2024 edition (OMB Control No. 2900-0858), which supersedes the July 2021 edition.
Who needs to file 21-4142a?
Veterans who want VA to get medical provider information from a non-VA source, such as a private doctor or hospital, use this form to name each provider or facility, the conditions treated and the treatment dates.
- Veteran as patient: complete Section I (items 1 to 5) and leave Section II blank.
- Patient other than the veteran: the form has a separate Section II, items 6 to 8, for the patient whose records VA is requesting. Enter that person's name, Social Security number and VA file number there, along with the veteran's information in Section I.
- More than five providers: the form has room for five; the form prints no instruction for additional providers, so use the VA contact channels below if you need guidance.
The form is not the authorization to disclose your personal treatment information. The VA directs you to VA Form 21-4142 for that purpose. Your obligation to respond is voluntary, according to the Privacy Act notice printed on the form, but if the information is incomplete or inaccurate, the health care provider may not be able to identify and locate your records and send a copy to VA.
When to file 21-4142a
Complete this form when you want VA to obtain information from a non-VA medical provider, such as a private doctor or hospital. The form prints no due date and no expiration of its own for your submission. The VA page for the form says it is used to give VA permission to get provider information like the name and address of a facility and your treatment dates, so it is typically sent whenever you need to identify those providers to VA. Gather each provider's address and your treatment dates in MM/DD/YYYY format before you start. If you need to know where your own claim stands or whether to use a different form, contact VA at https://ask.va.gov or toll-free at 1-800-827-1000 (TDD users: the Federal relay number is 711).
How to fill out 21-4142a
Read the Privacy Act notice first
The instructions at the top tell you to read the Privacy Act and Respondent Burden information on page 2 before completing the form. You may complete it online or by hand; by hand, print in ink, neatly, one letter per box.
Enter the veteran's name
Item 1: the veteran's name in the order First, Middle Initial, Last.
Enter identification numbers and birth date
Item 2: Social Security number. Item 3: VA file number. Item 4: date of birth in MM/DD/YYYY format. Item 5: veteran's service number, if applicable. The veteran's Social Security number also appears at the top of page 2.
Complete Section II if needed
Only if the records VA is requesting are for a patient other than the veteran: item 6, the patient's name; item 7, the patient's Social Security number; item 8, the patient's VA file number.
Name the provider or facility
Item 9A: the name of the provider or facility that treated you. Use items 10A to 13A for additional providers.
Describe the conditions treated
Item 9B: the conditions you are being treated for by that provider. Repeat in 10B to 13B for the other providers.
Enter the dates of treatment
Item 9C: the From and To dates, in MM/DD/YYYY format, of treatment by the provider listed in 9A. Repeat in 10C to 13C.
Enter the provider's address
Item 9D: number and street, apartment or unit number, city, state or province, country and ZIP or postal code. Use 10D to 13D for the other providers.
Add up to four more providers
Items 10 to 13 repeat the same four entries (A name, B conditions, C dates, D address) for a second through fifth provider. Leave unused blocks blank.
Review and download the completed PDF
Check names, numbers, dates and addresses. Download or print the completed PDF from FillingPDF and mail it as described under How to submit.
How to submit 21-4142a
You can mail the completed paper form to VA, and the VA's page for the form says you can submit your authorization online instead of sending the paper form.
- By mail: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
- Online: the VA's page for Form 21-4142a offers an online tool; start from https://www.va.gov/forms/21-4142a.
- Questions: https://ask.va.gov or 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
Do not send the completed form to the VA Reports Clearance Officer email address printed in the Respondent Burden notice; that address is only for comments on the burden estimate. Leave the "VA DATE STAMP" space blank. The form names no fee. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Mailing the form to the VA Reports Clearance Officer email address in the Respondent Burden notice; the form says not to send the completed form there.
- Sending the paper form to an address other than Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
- Writing in pencil or crowding letters when completing by hand; the form asks for ink, neat, legible print with one letter per box.
- Leaving out the time period for treatment in item 9C, 10C, 11C, 12C or 13C; the form asks for From and To dates in MM/DD/YYYY format.
- Omitting the Social Security number or giving it inaccurately; the form warns the provider may not be able to identify and locate your records.
- Filling Section II when the veteran is the patient, or skipping it when the records VA is requesting belong to someone else.
- Using this form when you need to authorize release of personal treatment information; VA points to Form 21-4142 for that purpose.
- Writing in the VA DATE STAMP space, which the form marks as not to be written in.
- Entering a statement you know to be false; the form states that willful false statements carry fine, imprisonment or both.
Frequently asked questions
What is VA Form 21-4142a used for?
VA Form 21-4142a is used to give VA the name and address of a non-VA provider or facility, such as a private doctor or hospital, and your treatment dates. According to the VA, it gives permission to gather that provider information.
What is the difference between VA Form 21-4142 and 21-4142a?
Form 21-4142a covers medical provider information such as a facility's name, address and treatment dates. VA describes Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), as the form that gives permission to obtain personal information like treatment, hospitalizations, psychotherapy or outpatient care.
Where do I mail VA Form 21-4142a?
Mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. Do not send it to the VA Reports Clearance Officer email address on page 2, which is only for comments on the burden estimate.
Can I submit the 21-4142a online?
Yes. The VA's page for the form says you can submit your authorization online instead of sending the paper form. You can also fill out the PDF on FillingPDF, but FillingPDF does not send it to VA; you mail the completed copy to the address above.
Do I have to give my Social Security number on the form?
Your response is voluntary and refusing to give your SSN alone will not result in a denial of benefits. However, if the information is incomplete or inaccurate, the provider may not be able to identify and locate your records, and VA uses your SSN to identify your claim file.
How many providers can I list on one form?
Five. Section III has blocks for items 9 through 13, each with the provider or facility name, conditions treated, dates of treatment and address. The form itself does not say what to do for more than five.
How do I fill out the form by hand?
Print in ink, neatly and legibly, with one letter per box, which the form says helps expedite processing. Enter dates as MM/DD/YYYY. You may also complete the form online instead of by hand.
Who do I contact with questions about the form?
Contact VA at https://ask.va.gov or call toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are also available at www.va.gov/vaforms.
Ready to fill out 21-4142a?
Fill out 21-4142a now