VA Form 21-4142a General Release for Medical Provider Information to the

OMB Control No. 2900-0001
Respondent Burden: 5 minutes
Expiration Date: XXXXXXXXX

DRAFT

GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION
TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
NOTE - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BELOW BEFORE COMPLETING THIS FORM.

INSTRUCTIONS - COMPLETE AND ATTACH THIS FORM WITH A SIGNED VA FORM 21-4142, AUTHORIZATION TO DISCLOSE
INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA). IF YOU HAVE MORE THAN THREE PROVIDERS, FILL OUT
ADDITIONAL COPIES OF THIS FORM.
SECTION I - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING
1. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

SECTION II - MEDICAL PROVIDER INFORMATION
4A. PROVIDER OR FACILITY NAME

4B. DATE(S) OF TREATMENT:

(Include the time period (month/year)
for the treatment by the provider listed in
Item 4A)

From:

To:

From:

To:

4C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)

4D. CITY

4E. STATE AND ZIP CODE

5A. PROVIDER OR FACILITY NAME

4F. PROVIDER OR FACILITY TELEPHONE NUMBER (Include Area Code)

5B. DATE(S) OF TREATMENT:

(Include the time period (month/year)
for the treatment by the provider listed in
Item 5A)

From:

To:

From:

To:

5C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)

5D. CITY

5E. STATE AND ZIP CODE

6A. PROVIDER OR FACILITY NAME

5F. PROVIDER OR FACILITY TELEPHONE NUMBER (Include Area Code)

6B. DATE(S) OF TREATMENT:

(Include the time period (month/year)
for the treatment by the provider listed in
Item 6A)

From:

To:

From:

To:

6C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)

6D. CITY

6E. STATE AND ZIP CODE

6F. PROVIDER OR FACILITY TELEPHONE NUMBER (Include Area Code)

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations
1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the
United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of
records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.
However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed may not be able to identify
and locate your records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us
your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless
the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975 and still in effect.
RESPONDENT BURDEN: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes
to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB control numbers
can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM
XXX 2014

21-4142a