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VA 21-4142 2021-2024 free printable template

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OMB Control No. 2900-0001 Respondent Burden: 5 minutes Expiration Date: 8/31/2017 AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA) NOTE - PLEASE READ THE ENTIRE FORM
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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

Instructions and Help about va form 21 4142 printable

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

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People Also Ask about va form 21 4142

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