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

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

OMB: 2900-0858

IC ID: 228502

Information Collection (IC) Details

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Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a)
 
No Modified
 
Voluntary
 
45 CFR 160 45 CFR 164 45 CFR 2

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form VA Form 21-4142 General Release for Medical Provider Information to Department of Veterans Affairs (VA) 21-4142(11-02-20).pdf www.va.gov/vaforms Yes No Fillable Printable
Form VA Form 21-4142a General Release for Medical Provider Information to The Department of Veterans Affairs (VA) 21-4142a(11-02-20).pdf www.va.gov/vaforms Yes No Fillable Printable

General Government Legislative Functions

58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment Records - VA  84 FR 4138

127,397 0
   
Individuals or Households
 
   75 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 127,397 0 -5,003 0 132,400 0
Annual IC Time Burden (Hours) 10,616 0 -417 0 11,033 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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