Information Collection

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

IC 228502 under ICR 201709-2900-024 · OMB 2900-0858.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0858 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-4142 Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)	Form
21-4142 General Release for Medical Provider Information to the VAF 21-4142.pdf www.va.gov/vaforms/	Form
21-4142a General Release for Medical Provider Information to the VAF 21-4142a.pdf www.va.gov/vaforms/	Form

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4142	General Release for Medical Provider Information to the VA	VAF 21-4142.pdf	https://www.va.gov/vaforms/	Yes	No	Fillable Printable
Form	21-4142a	General Release for Medical Provider Information to the VA	VAF 21-4142a.pdf	https://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 132,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	132,400	132,400
Annual IC Time Burden (Hours)	11,033	11,033
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.