General Release for Medical Provider Information to the Department of Veterans Affairs
This is a general authorization form that accompanies the 21-4142. It provides broader authorization language that some medical providers require before releasing records.
Used in these claim stages:
Last updated by VA: January 1, 2024
How to Complete This Form
This form is typically submitted along with VA Form 21-4142:
**Section I - Veteran Information**
Your identifying information.
**Section II - General Authorization**
This section contains standard authorization language allowing release of:
- Medical records
- Mental health records
- Drug and alcohol treatment records
- HIV/AIDS information
- Other sensitive medical information
**Section III - Signature**
Sign and date the form.
**Note:** Some providers require this broader authorization language in addition to the 21-4142. Submit both forms together to ensure VA can obtain your records.
Helpful Tips
- Submit this form along with every 21-4142
- This broader language helps with providers who have strict release policies
- Especially important for mental health and substance abuse records
- The general language covers most HIPAA-protected information
- Some providers won't release records without this additional form
Common Mistakes to Avoid
- Not submitting this along with the 21-4142
- Forgetting to sign the form
- Not realizing some providers need both forms
Deadline Information
Same as 21-4142 - valid for 180 days from signing.