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

Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)

VAF 21-4142a

Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)

OMB: 2900-0858

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0858 can be found here:

2021-05-24 - Reinstatement with change of a previously approved collection

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File Modified	2017-06-20
File Created	2017-06-20