OMB control number
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 ยท VA.
OMB 2900-0858
VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather the necessary information to request medical provider information to the VA. Without the information solicited by these forms, VA would be unable to determine eligibility, and benefits would not be properly paid.
The latest form for Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a) expires 2027-08-31 and is listed under ICR 202404-2900-008.
Latest Forms, Documents, and Supporting Material
| 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 |
| 2024-14847, 30-Day FRN (2900-0858, VAF21-4142, 4142a).pdf | Supplementary Document |
| 2024-09336, 60-Day FRN (VAF21-4142, 4142a).pdf | Supplementary Document |
 2900-0858, Supporting Statement (VAF21-4142, 4142a).docx | Supporting Statement A |
 Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a) |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202404-2900-008 | Revision of a currently approved collection | 2024-07-09 | Approved without change | |
| 202009-2900-020 | Reinstatement with change of a previously approved collection | 2021-05-24 | Approved without change | |
| 201709-2900-024 | New collection (Request for a new OMB Control Number) | 2017-11-16 | Approved without change |