Download Fillable VA form 21-4142 | Consent to Release Information

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Fillable VA form 21-4142 | Consent to Release Information


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VA Form 21-4142 is a medical release form that must be on file with Veteran’s Affairs prior to any review of any disability or medical claims. This is the form that is required to provide permission and consent for the release of any medical information and/or treatment received by you to the Veterans Administration.

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How to Fill-in

  • Step 1 – General Identification

Boxes 1,2 and box number 4 must be filled in with the Veteran’s name, file number and SS number. If anyone else is seeking benefits on behalf of the veteran, they must fill in box 3,5, and 6 with their information as well.

  • Step 2 – Medical Information

You will need to provide all information on all medical records you will allow Veterans Affairs to retrieve. Gather all names addresses and phone numbers for any medical facilities who will be involved any retrieval of any medical records. Dates, conditions and illnesses must be included with each source. In box 8 provide additional information that may assist the VA in acquiring all needed information.

  • Step 3 – Privacy Information

You must carefully read through all of the privacy information on this form. You will then check authorization box in 9-c. In box 10 certification with signature and personal information will be required by the Veteran themselves, legal counsel or a representative. It’s important that contact information is provided.

  • Step 4 – Witness Statement

In Box 11 a witness must sign and date your form. Its not always needed, however, the VA may need a witness statement when they are seeking your medical information. Once this is completed you will need to make a copy of this entire form and keep it on file in the event further claims need to be made. After making copies for your records, your form will be ready for submission to the VA. Submit to the appropriate office to begin your claim(s) processes.

 

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