Form 21-4142 Authorization to Disclose Information to VA

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

VA Form 21-4142 (OMB Exp. 7-31-24)

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

OMB: 2900-0858