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

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

OMB: 2900-0858

IC ID: 228502

Documents and Forms

Document Name Document Type
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
21-4142 Authorization to Disclose Information to VA VA Form 21-4142 (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form
21-4142a General Release of Medical Provider Information to VA VA Form 21-4142a (OMB Exp. 7-31-24).pdf www.va.gov/vaforms Form