Edit VA Form 21-4142 online free, or download the PDF
VA Medical Records Release Form: Authorization to Disclose Information to the Department of Veterans Affairs (VA)
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VA Form 21-4142 in short
VA Form 21-4142 is your signed permission for VA to request your records from non-VA sources, such as a private doctor, hospital, employer or insurer. VA uses it to get evidence for your claim when you have not sent those records yourself. It is the consent and signature part. The list of providers goes on the companion VA Form 21-4142a.
| Issued by | U.S. Department of Veterans Affairs (VA), Veterans Benefits Administration |
|---|---|
| Current version | Rev. August 2024 (checked 2026-10-25) |
| Who fills it in | The veteran or claimant whose records VA is asking for. Item 16 lets someone else sign, such as a court-appointed representative, if they give their relationship and details. Court appointments must include the docket number, county and state. |
| Who receives it | VA. VA then sends the authorization to the sources you name so they can release records to VA. |
| Where to send it | VA's form page says you can submit the authorization online. Page 3 of the PDF says VA recommends electronic submission, for example Direct Upload at access.va.gov, and also accepts mail or delivery in person at a VA regional office. Mail by claim type: compensation claims to Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444; pension and survivors benefit claims to Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365; fiduciary to Fiduciary Intake, PO Box 95211, Lakeland, FL 33804-5211; Board of Veterans' Appeals to PO Box 27063, Washington, DC 20038. |
| Deadline | The form has no filing deadline of its own. The authorization expires 12 months after the date you sign it, unless you revoke it sooner. Follow any date in a VA letter for the claim it supports. |
| Fee | No VA filing fee. The form quotes 38 C.F.R. 3.159(c): VA will not pay any fees a records custodian charges to provide the records. |
| Official links | Official page · Official PDF |
What changed
The AUG 2024 edition supersedes the JUL 2021 edition, as printed on the form. VA did not publish a list of changes.
How to fill out VA Form 21-4142, line by line
| Section I, items 1 to 5 | Veteran's identification Name, Social Security number, VA file number if any, date of birth (MM/DD/YYYY) and service number if any. The form asks for one letter per box if you fill it by hand. |
| Section I, items 6 to 8 | Veteran's contact details Mailing address, phone number and an optional email. There is a box to agree to receive electronic correspondence from VA about your claim. |
| Section II, items 9 to 11 | Patient, if not the veteran Fill this in only when the records are about someone other than the veteran, for example a dependent. Give the patient's name, Social Security number and VA file number. |
| Sections III and IV | Sources and records covered These sections are preprinted. They list the kinds of sources and records the authorization covers, including mental health, substance use, HIV and genetic test records. You do not write in them. |
| Section V, item 12 | Limits on your consent Write any limits here, for example a date range or a condition you do not want shared. If you leave it blank, the form says there is no limitation. |
| Section V, items 13 and 14 | Signature and date Both are marked required. The 12-month expiry runs from the date you enter here. |
| Section V, items 15 and 16 | Printed name and relationship Print the signer's name. If the signer is not the veteran or claimant, give their full name, title, organization and address, plus court details for a court appointment. |
Common mistakes to avoid
- Filling it out when you already sent the private records or plan to get them yourself. The form says this is not needed and will lengthen processing time.
- Using it to ask for VA medical records. The form says it is not needed for VA records.
- Leaving out the provider list. The names, dates and addresses of your providers go on VA Form 21-4142a, not on this form.
- Forgetting to sign or date items 13 and 14, which the form marks as required.
- Writing vague limits in item 12. If you add limits, state them clearly, because a blank item 12 means no limitation.
- Expecting VA to pay copying fees. The form says VA will not pay fees a custodian charges.
- Signing for someone else without giving the relationship and contact details asked for in item 16.
Questions about VA Form 21-4142
What is the difference between VA Form 21-4142 and 21-4142a?
VA Form 21-4142 is the authorization: it covers what VA may get and holds your signature. VA Form 21-4142a is where you list each private provider, the conditions treated, the treatment dates and the address. VA publishes the 21-4142a as pages 4 and 5 of the 21-4142 PDF.
How long is VA Form 21-4142 valid?
The form says the authorization is good for 12 months from the date you sign it, unless you revoke it in writing first.
Do I need VA Form 21-4142 for VA medical records?
No. The form says it is not needed to request VA medical records.
Can I revoke the authorization?
Yes. The form says you can revoke it in writing at any time, except for anything a source already did in reliance on it. You send the revocation to the VA regional office handling your claim, or the Board of Veterans' Appeals if it relates to an appeal, and a copy to each source.
Can I submit VA Form 21-4142 online?
Yes. VA's form page says you can submit your authorization online instead of sending the paper form.
Does it cover mental health or substance use records?
Yes, unless you limit it. Section IV lists mental health records (excluding psychotherapy notes), substance use, sickle cell anemia, HIV and genetic test records. You can add limits in item 12.
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Sources
Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the U.S. Department of Veterans Affairs or any government agency. This page is general information, not legal or tax advice.