Authorization to Disclose Information to the Department of Veterans Affairs
Use this form to authorize non-VA medical providers, hospitals, or other organizations to release your medical records to the VA in support of your claim.
Used in these claim stages:
Last updated by VA: January 1, 2024
How to Complete This Form
Complete a separate form for each provider:
**Section I - Veteran Information**
Your personal information, VA file number, and contact details.
**Section II - Provider Information**
For the medical provider or facility:
- Name of provider/facility
- Complete address
- Phone and fax numbers
- Type of provider (hospital, doctor, clinic, etc.)
**Section III - Information to be Released**
- Dates of treatment (from/to)
- Conditions treated
- Type of records requested (all records, specific records, etc.)
**Section IV - Authorization**
Sign and date the authorization. Note: This authorization is valid for 180 days from signing.
**Important:** This form authorizes release TO the VA. It does not authorize VA to release your records to others.
Helpful Tips
- Submit a separate 4142 for each medical provider
- Be specific about the date range of records needed
- Include the provider's fax number - VA often faxes these requests
- Keep copies of all authorizations you submit
- Follow up if VA doesn't seem to have obtained the records
- You can also request records yourself and submit them directly
- Consider submitting 21-4142a (general release) along with this form
Common Mistakes to Avoid
- Using an old or incorrect address for the provider
- Not specifying the correct date range
- Forgetting to sign and date the form
- Submitting one form for multiple providers (need separate forms)
- Not following up to ensure VA obtained the records
Deadline Information
The authorization is valid for 180 days from the date you sign it. If VA hasn't obtained the records within that time, you may need to submit a new authorization.