VA Form 21-4142 Authorization to Disclose Information to the Department

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

AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
NOTE - PLEASE READ THE ENTIRE FORM (both pages) BEFORE SIGNING IN ITEM 11 BELOW.

SECTION I - RECORDS TO BE RELEASED TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of: All my medical records; including education records and other information
related to my ability to perform tasks of daily living. This includes specific permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including,
but not limited to:
a. Psychological, psychiatric, or other mental impairment(s) excluding "psychotherapy notes" as defined in 45 C.F.R. §164.501,
b. Drug abuse, alcoholism, or other substance abuse,
c. Sickle cell anemia,
d. Records which may indicate the presence of a communicable or non-communicable disease; and tests for or records of
HIV/AIDS,
e. Gene-related impairments (including genetic test results).
2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
3. Copies of educational tests or evaluations, including individualized Educational Programs, triennial assessments, psychological and speech
evaluations, and any other records that can help evaluate function; including teachers' observations and evaluations.
4. Information created within 12 months after the date this authorization is signed in Item 11, as well as past information.
YOU SHOULD NOT COMPLETE THIS FORM UNLESS YOU WANT THE VA TO OBTAIN PRIVATE TREATMENT RECORDS ON YOUR BEHALF. IF YOU HAVE
ALREADY PROVIDED THESE RECORDS OR INTEND TO OBTAIN THEM YOURSELF, THERE IS NO NEED TO FILL OUT THIS FORM. DOING SO WILL LENGTHEN
YOUR CLAIM PROCESSING TIME.
IMPORTANT - In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees charged by a custodian to provide records requested."

SECTION II - VETERAN IDENTIFICATION
1. LAST NAME - FIRST NAME - MIDDLE NAME (Type or print)

2. DATE OF BIRTH (MM,DD,YYYY)

3. SOCIAL SECURITY NUMBER/VA FILE NUMBER

SECTION III - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING
4. LAST NAME - FIRST NAME - MIDDLE NAME (Type or print)

5. DATE OF BIRTH (MM,DD,YYYY)

6. SOCIAL SECURITY NUMBER

7. STREET ADDRESS

8. CITY, STATE, ZIP CODE

9. TELEPHONE NUMBER (Include Area Code)

SECTION IV - INFORMATION REGARDING SOURCE OF RECORD(S)

SOURCE OF RECORD(S):
• ALL medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment,
and VA health care facilities,
• Social workers/rehabilitation counselors,
• Consulting examiners used by VA,
• Employers, insurance companies, workers' compensation programs, and
• Others who may know about my condition (family, neighbors, friends, public officials).

SECTION V - AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE
10. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):

TO WHOM: The Department of Veterans Affairs (VA).
PURPOSE: Determining my eligibility for benefits, and whether I can manage such benefits.
EXPIRES: This authorization is good for 12 months from the date shown in Item 12.
• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above in Section I.
• I understand that there are some circumstances in which this information may be re-disclosed to other parties (See page 2 for details).
• I may write to VA source(s) to revoke this authorization at any time (See page 2 for details).
• VA will give me a copy of this form, if I ask; I may also ask the source(s) to allow me to inspect or get a copy of material to be disclosed.
• I have read both pages of this form and agree to the disclosures above from the types of sources listed. See Patient Acknowledgement on
Page 2.

11. SIGNATURE OF PERSON AUTHORIZING DISCLOSURE (Required)

12. DATE SIGNED (MM,DD,YYYY) (Required)

13. PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last)

14. TELEPHONE NUMBER (Include Area Code)

15. RELATIONSHIP TO VETERAN/CLAIMANT (If other than self, please provide full name, title, organization, city, State, and ZIP code. All court appointments must include
docket number, county, and State)

NOTE: This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical and other information under
P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; 42 U.S.C. §290dd-2; 42 C.F.R. part 2, and State Law.
VA FORM
XXX 2014

21-4142

Supersedes VA Form 21-4142, FEB 2012,
Which Will Not Be Used.

PAGE 1

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, 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 source 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.
If you do not revoke this authorization, it will automatically expire in 12 months from the date you sign and date the form. Signing this
form is voluntary, but failing to sign it, or revoking it before we receive necessary information could prevent an accurate or timely
decision on your claim, and could result in denial or loss of benefits. Although the information we obtain with this form is almost never
used for any purpose other than those stated above, the information may be disclosed by VA without your consent if authorized by
Federal laws such as the Privacy Act.
State laws that are contrary to the Privacy Rule are preempted by the Federal Requirement, which means that the Federal requirement
will apply.
Under the Government Paperwork Elimination Act (GPEA) (Public Law 105-277), the Office of Management and Budget (OMB)
ensures that agencies, when practicable, provide for the option of electronic maintenance, submission of disclosure of information and
for the use and acceptance of electronic signatures. GPEA states that electronic records submitted or maintained in accordance with
the procedures developed by OMB, or electronic signature or other forms of electronic authentication used in accordance with such
procedures, "shall not be denied legal effect, validity, or enforceability merely because such records are in electronic form" (Public Law
105-277, section 1707.
RESPONDENT BURDEN: We need this information and your written authorization to obtain your treatment records to help us get the
information required to process your claim. Title 38, United States Code, allows us to ask for this information. You can provide this
authorization by signing VA Form 21-4142. Federal law permits sources with information about you to release that information if you
sign a single authorization to release all your information from all possible sources. We will make copies of it for each source. A few
States, and some individual sources of information, require that the authorization specifically name the source that you authorize to
release personal information. In those cases, we may ask you to sign one authorization for each source and we may contact you again
if we need you to sign more authorizations. 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. If you use the
Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.

PATIENT ACKNOWLEDGMENT - I HEREBY AUTHORIZE the sources listed in Section IV, to release any information that may have
been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will
use this information in determining my eligibility to veterans benefits I have claimed. I understand that the source being asked to
provide the Veterans Benefits Administration with records under this authorization may not require me to execute this authorization
before it provides me with treatment, payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. I
understand that once my source sends this information to VA under this authorization, the information will no longer be protected by
the HIPAA Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a, and VA may disclose this information as
authorized by law. I also understand that I may revoke this authorization in writing, at any time except to the extent a source of
information has already relied on it to take an action. To revoke, I must send a written statement to the VA Regional Office handling my
claim or the Board of Veterans' Appeals (if my claim is related to an appeal) and also send a copy directly to any of my sources that I
no longer wish to disclose information about me. I understand that VA may use information disclosed prior to revocation to decide my
claim.

VA FORM 21-4142, XXX 2014

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