Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)

ICR 202404-2900-008

OMB: 2900-0858

Federal Form Document

Forms and Documents

Document Name	Status
Form 21-4142 Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a) Form	Modified
2024-14847, 30-Day FRN (2900-0858, VAF21-4142, 4142a).pdf Supplementary Document	2024-07-09
2024-09336, 60-Day FRN (VAF21-4142, 4142a).pdf Supplementary Document	2024-06-26
2900-0858, Supporting Statement (VAF21-4142, 4142a).docx Supporting Statement A	2024-07-09

IC Document Collections

IC ID	Document Title	Status
228502	Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a) Form	Modified