VA 21-4142 2024-2025 free printable template

OMB Control No. 2900-0858 Respondent Burden: 5 minutes Expiration Date: 8/31/2027 VA DATE STAMP (DO NOT WRITE IN THIS SPACE) AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS

How to fill out va form 21 4142a fillable

How to fill out va form 21-4142

1. Obtain VA Form 21-4142 from the official VA website or your local VA office.
2. Carefully read the form instructions to understand the required information.
3. Fill out the claimant's name, social security number, and contact information in the designated fields.
4. Provide information about the healthcare provider or facility, including name, address, and phone number.
5. List the dates of treatment or care received from the provider.
6. Sign and date the form to authorize the release of medical records.
7. Submit the completed form to the VA along with your claim or as directed.

Who needs va form 21-4142?

1. Veterans seeking disability benefits.
2. Survivors applying for survivors’ benefits.
3. Any individual needing to authorize the release of private medical records to the VA.

• Who needs a VA Form 21-4142?
• What is fillable VA Form 21-4142 for?
• Is VA Form 21-4142 accompanied by other forms?
• • When is VA Form 21-4142 due?
  • How do I fill out VA Form 21-4142?
  • Where do I send VA Form 21-4142?

Who needs a VA Form 21-4142?

A VA Form 21-4142 is known as an Authorization and Consent to Release Information to the US Department of Veteran Affairs. It is filled out by the citizens who are going to claim a disability. The form VA 21-4142 will be used by the Department of Veteran Affairs for processing and reviewing disability or medical claims filed by US Army veterans.

What is fillable VA Form 21-4142 for?

The completion of the Authorization and Consent to Release Information form provides permission to obtain medical records from the claimant physician or healthcare provider to the Veteran’s Administration.

Is VA Form 21-4142 accompanied by other forms?

The VA 21-4142 fillable form is used as a supplement itself, preceding submission of a claim for VA benefits.

When is VA Form 21-4142 due?

The VA 21 4142 Authorization form is in effect for 12 months. However, the Authorization and Consent can be revoked by the claimant when considered necessary. If the revocation doesn’t happen, the authorization will automatically expire in 12 months after the date indicated in the form.

How do I fill out VA Form 21-4142?

The information to provide on the printable VA Form 21-4142 must clearly indicate:

• Veteran/Claimant Identification (name, date of birth, SSN)
• Source of Pertinent Information (identification of the medical treatment provider and its contact information, dates of treatment, disabilities)
• Consent to Release Information (signature, mailing address, date, etc.)

Where do I send VA Form 21-4142?

The properly filled out VA 21-4142 Form must be submitted to the local VA office.

Video instructions and help with filling out and completing va form 21 4142 fillable

Instructions and Help about 21 4142

Laws dot-com legal forms guide a VA Form 21 – 41 42 is a United States Department of Veteran Affairs form used to authorize and provide consent for the release of medical information to the VA this form must be on file before Veterans Affairs can review any medical or disability claims the VA Form 21 – 41 42 is available on the Veterans Affairs documentation website or can be supplied through a local Veterans Affairs office the first section is used for general identification information boxes 1 2 camp; 4 are to be filled out with the veterans name file number and social security number these boxes must be filled in if a claimant other than the veteran is seeking benefits on behalf of the veteran they must provide their name relationship and social security number in boxes 3 5 camp; 6 in section 2 you must identify all sources of medical information for which you are allowing Veterans Affairs to have you must include the name and addresses for all offices for which your medical or disability claim involves you must also include the dates and conditions or illnesses for which you were treated inbox aid provide any additional comments about your consent that will be helpful for Veterans Affairs to seek your medical history and to view them section 3 provides all the important privacy information that the Department of Veterans Affairs will be held to read all the information and check the authorization box in box 9 see in box 10 the veteran the claimant or a legal representative must certify with their signature their consent of the VA form 21 – 41 42 provide your contact information including address and phone numbers this is important as Veterans Affairs may need to contact you in regard to this form and to further obtain your consent for additional information they need for processing your claims in box 11 it is important that you have a witness sign and date the form while this is not necessary for all medical records Veterans Affairs may need a witness statement when seeking some of your records once completed your VA Form 21 – 41 42 is ready for submission to Veterans Affairs keep a copy on record as you may need to submit an additional consent forms if you make additional claims to watch more videos please make sure to visit laws dot-com

People Also Ask about trial va21 2142

What is the latest VA Form 21 526ez?

Veterans and Service Member should use this form to submit a claim for veterans disability compensation and related compensation benefits.

Where can I find Dbq?

Where to Find a VA DBQ. You can find 70 different VA DBQs on the US Department of Veteran's Affairs website. You will want to find the VA DBQ that matches your condition. You can either search by DBQ List by Form Name or DBQ List by Symptoms.

What is a VA Form 21 4142?

Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.

Who completes the VA Form 21 4192?

Use VA Form 21-4192 if you're a Veteran and you need your most recent employer to send us information so you can apply for Individual Unemployability disability benefits. Your most recent employer must complete and submit this form.

What is the VA file number?

Your VA FILE NUMBER is the number that appears on your VA benefit checks and all mail that we've sent you. Usually, this VA FILE NUMBER is the veteran's Social Security Number; however, this FILE NUMBER can be an eight digit number. ITEM 3D. Your SUFFIX LETTER indicates your relationship to the veteran.

What is VA Form 4142a?

Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.

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What is va form 21-4142?

VA Form 21-4142 is a form used by veterans to authorize the Department of Veterans Affairs to obtain medical records from health care providers.

Who is required to file va form 21-4142?

Veterans who are seeking disability benefits or other services from the VA and need to provide evidence from private medical providers are required to file VA Form 21-4142.

How to fill out va form 21-4142?

To fill out VA Form 21-4142, provide your personal information, the names of the health care providers, the locations of the records, and the dates of treatment or services received.

What is the purpose of va form 21-4142?

The purpose of VA Form 21-4142 is to allow the VA to request and obtain medical records and information from private healthcare providers to support a veteran's claim.

What information must be reported on va form 21-4142?

The information required includes the veteran's name, social security number, the names and addresses of health care providers, the specific records requested, and the dates of treatment.