Form VA 21-4142 Authorization and Consent to Release Information to the Department of Veterans Affairs
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Category: Military Format: PDF Form Name: VBA-21-4142-ARE.pdf |
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INSTRUCTIONS : AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA) (VA Form 21-4142) A VA Form 21-4142 is a United States Department of Veteran Affairs form used to authorize and provide consent for the release of medical information to the VA. This form must be on file before Veterans Affairs can review any medical or disability claims. The VA Form 21-4142 is available on the Veterans Affairs documentation website or can be supplied through a local Veterans Affairs office. The first Section is used for general identification information 1. Boxes 1, 2 and 4 are to be filled out with the veteran's name, file number, and social security number. These boxes must be filled in. 2. If a claimant other than the veteran is seeking benefits on behalf of the veteran, they must provide their name, relationship, and social security number in boxes 3, 5, and 6. In Section II, you must identify all sources of medical information for which you are allowing Veterans Affairs to have. 3. You must include the name and addresses of all offices for which your medical or disability claim involves. You must also include the dates and conditions or illnesses for which you were treated. 4. In box 8, provide any additional comments about your consent that will be helpful for Veterans Affairs to seek your medical history and to view them. Section III provides all of the important privacy information that the Department of Veterans Affairs will be held. 5. Read all of the information and check the authorization box in box 9c. In box 10, the veteran, the claimant, or a legal representative must certify with their signature their consent of the Va Form 21-4142. 6. Provide your contact information including address and phone numbers. This is important as Veterans Affairs may need to contact you in regards to this form and to further obtain your consent for additional information they need for processing your claims. In box 11, it is important that you have a witness sign and date the form. While this is not necessary for all medical records, Veterans Affairs may need a witness statement when seeking some of your records. Once completed, your VA Form 21-4142 is ready for submission to Veterans Affairs. Keep a copy on record, as you may need to submit additional consent forms if you make additional claims. |
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