VA Form 21-4142 and 21-4142a: Release Private Records

What is VA Form 21-4142 and 21-4142a?

VA Form 21-4142 is your signed authorization for medical sources and others to release information about you to VA, so VA can decide your benefits and whether you can manage them. VA Form 21-4142a, General Release for Medical Provider Information, comes with it and names each provider. The form says to use them only if you want VA to get private treatment records for you: you don't need them for VA medical records, or for records you have sent or will send yourself.

On 21-4142 you identify the veteran and, if different, the patient, can write a limit on what's released, then sign, date and print your name and relationship. On 21-4142a you list up to five providers or facilities, the conditions treated, the dates of treatment and each provider's address.

FileIt asks for the veteran's details once and repeats them on both forms, pre-fills them from your vault, and prints capitals one letter per box on VA's own PDF (AUG 2024 edition). The filled forms are saved in the person's vault folder, ready to sign by hand or through FileIt eSignature. You send them to VA yourself; FileIt never submits them.

Who fills it: The veteran or claimant, or someone authorized to sign for them, such as a court-appointed representative.
Lasts: The form says the authorization is good for 12 months from the date signed, unless you revoke it.
Covers: All medical records, including mental health, substance abuse, sickle cell, HIV and genetic information, unless you limit it in item 12.
Fees: The form quotes 38 CFR 3.159(c): VA will not pay any fees a custodian charges for records.
Send to: The intake center for your claim type on page 3 (compensation: Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444), or upload it.
Edition: VA Forms 21-4142 and 21-4142a, AUG 2024 (OMB No. 2900-0858, expires 08/31/2027)

Who needs to fill out VA Form 21-4142 and 21-4142a?

Veterans whose disability claim depends on records from private doctors, hospitals or clinics.
Claimants filing a Supplemental Claim who want VA to gather private or Vet Center records for them.
Survivors or dependents whose own private records support a claim.
Guardians and other authorized people signing for a claimant who can't sign.

When to use VA Form 21-4142 and 21-4142a

When you file a claim or Supplemental Claim and want VA to request private treatment records instead of sending them yourself.
When VA writes asking for an authorization to get records you told it about.
Again after 12 months, if VA still needs records once the earlier authorization has expired.

What you need before you start

The veteran's name, Social Security number, VA file number, date of birth and service number.
The patient's name, SSN and file number, if the records are about someone other than the veteran.
Each provider's or facility's name and full address, the conditions they treated, and the dates of treatment.
Any limit you want on the records released.
If you sign for someone else, your full name, title, organization and address, and for a court appointment the docket number, county and state.

What’s on VA Form 21-4142 and 21-4142a

The 2024 edition has 5 pages. FileIt asks for it in 8 parts, and it is signed by Veteran, claimant or authorized signer:

Section I: Veteran identification informationVeteran, claimant or authorized signer
Section II: Patient identification (if other than the veteran)Veteran, claimant or authorized signer
Section V: Authorization and consentVeteran, claimant or authorized signer
Form 21-4142a: Provider 1 (item 9)Veteran, claimant or authorized signer
Form 21-4142a: Provider 2 (item 10)Veteran, claimant or authorized signer
Form 21-4142a: Provider 3 (item 11)Veteran, claimant or authorized signer
Form 21-4142a: Provider 4 (item 12)Veteran, claimant or authorized signer
Form 21-4142a: Provider 5 (item 13)Veteran, claimant or authorized signer

How to fill out VA Form 21-4142 and 21-4142a, step by step

1 21-4142 Section I: Veteran

Name, SSN, VA file number, date of birth, service number, mailing address, phone and email, plus a box to agree to receive electronic correspondence from VA about your claim.

2 21-4142 Section II: Patient

Only if the records are about someone other than the veteran: their name, SSN and VA file number.

3 21-4142 Sections III and IV

These are printed: the sources covered (medical sources, social workers, VA's consulting examiners, employers and insurers, and others who know about your condition) and the records released, including information from the 12 months after you sign.

4 21-4142 Section V: Consent and signature

Write any limitation in item 12, or leave it blank for no limit. Sign item 13, date item 14, print your name in item 15 and, if you aren't the veteran or claimant, give your relationship in item 16.

5 21-4142a: Providers

For each of up to five providers: the name, the conditions you were treated for, the treatment dates from and to, and the street address. The veteran's and patient's details from 21-4142 print again at the top.

Common mistakes to avoid

Filing these forms for VA medical center records, which the form says VA can get without them.
Leaving out a provider's full address, so VA can't send the request.
Writing a limitation so narrow that it shuts out the records your claim needs.
Sending 21-4142 without 21-4142a, which is where the providers are named.
Forgetting the date in item 14, which the form marks as required and from which the 12 months run.

After you fill it out

Sign and date 21-4142, by hand or with FileIt eSignature, and send both forms to VA together.

Keep the filed PDF in your vault, with a note of the date signed, so you know when the 12 months end.

To revoke the authorization later, the form says to write to the VA Regional Office handling your claim, or the Board if it's an appeal, and to each source.

Fill out VA Form 21-4142 and 21-4142a online with FileIt

Pick the person. Choose someone from People and FileIt fills in their name, date of birth, address and other details it already knows.
Answer plain-language questions. One part of the form at a time, with the official help text beside each question — 78 fields in all. Your answers save as you go.
Check the live preview. Watch your answers land on the real U.S. Department of Veterans Affairs (VBA) form, and let FileIt do any worksheet arithmetic.
Generate the official PDF. FileIt prints your answers into the agency’s own PDF and files it in that person’s folder in your vault. Sign it, or send it for e-signature.

FileIt fills the form — it never files or submits anything for you. Deliver the finished form to whoever asked for it, the way the form’s instructions say.

Start VA Form 21-4142 and 21-4142a now — it’s free

VA Form 21-4142 and 21-4142a: frequently asked questions

Do I need this form for VA hospital records?

No. The form says it is not needed to request VA medical records, and the Supplemental Claim form says VA can get VA medical center and military treatment records without consent.

How long does the authorization last?

12 months from the date in item 14, unless you revoke it first in writing.

Can I limit what's released?

Yes. Item 12 holds any limitation. Left blank, the form says there is no limitation on the records released.

How many providers can I list?

21-4142a has room for five providers, items 9 to 13.

Will VA pay my doctor's records fee?

No. The form says VA will not pay any fees a custodian charges to provide the records.

Official sources

Blank form (PDF), published by U.S. Department of Veterans Affairs (VBA): https://www.vba.va.gov/pubs/forms/VBA-21-4142-ARE.pdf
Official instructions and guidance: https://www.va.gov/find-forms/about-form-21-4142/
Edition shown on this page: VA Forms 21-4142 and 21-4142a, AUG 2024 (OMB No. 2900-0858, expires 08/31/2027) (checked 2026-10-19).

FileIt is not affiliated with or endorsed by U.S. Department of Veterans Affairs (VBA) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-19.