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VA Medical Provider Information Form: General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
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VA Form 21-4142a in short
VA Form 21-4142a is where you list the non-VA doctors and facilities that treated you, so VA can ask them for records. For each provider you give the name, the conditions treated, the treatment dates and the address. It has room for five providers. It does not have a signature section; the signed permission is on VA Form 21-4142.
| 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 who wants VA to get private treatment records. Section II is for cases where the records are about a patient other than the veteran. |
| Who receives it | VA, which uses the details to contact each provider listed. |
| Where to send it | The form says to mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. VA's form page says you can also submit the authorization online. |
| Deadline | No deadline of its own. Send it with or soon after the claim it supports, or by any date in a VA letter. |
| 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 21-4142a, line by line
| Section I, items 1 to 5 | Veteran's identification Name, Social Security number, VA file number, date of birth and service number if any. The veteran's Social Security number is repeated at the top of page 2. |
| Section II, items 6 to 8 | Patient, if not the veteran Only when the records are about another person. Give that person's name, Social Security number and VA file number. |
| Items 9A, 10A, 11A, 12A, 13A | Provider or facility name One provider per block. Use the name the provider uses on its records, such as the hospital or clinic name. |
| Items 9B to 13B | Conditions treated List the conditions that provider treated you for. Keep it to conditions that matter for your claim. |
| Items 9C to 13C | Dates of treatment Give the From and To dates (MM/DD/YYYY) for treatment by that provider. A date range helps the provider find the right records. |
| Items 9D to 13D | Provider address Full street address, city, state, ZIP code and country. VA needs a usable address to send the request. |
Common mistakes to avoid
- Sending it without a signed VA Form 21-4142. This form has no signature section of its own.
- Listing more than one provider in a single block. Each block is for one provider or facility.
- Leaving treatment dates blank, which makes it harder for the provider to find records.
- Giving a billing office or old address instead of the provider's records address.
- Listing VA medical centers. VA Form 21-4142 says the authorization is not needed for VA medical records.
- Listing a provider whose records you already sent to VA. The 21-4142 says asking VA to get records you already provided will lengthen processing time.
Questions about VA Form 21-4142a
How is VA Form 21-4142a different from 21-4142?
VA Form 21-4142a only lists provider details: name, conditions, dates and address. VA Form 21-4142 is the signed authorization that lets VA request records. The 21-4142 PDF includes the 21-4142a as its last two pages.
How many providers fit on one VA Form 21-4142a?
Five. Items 9 to 13 each hold one provider or facility. If you have more, you can fill in another copy of the form.
Where do I mail VA Form 21-4142a?
The form says to mail it to the Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Do I sign VA Form 21-4142a?
The 21-4142a has no signature item. The signature and date are items 13 and 14 on VA Form 21-4142.
Can I submit it online?
Yes. VA's form page says you can submit your authorization online instead of the paper form.
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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.