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Use this form to provide your written authorization to obtain your treatment records, so the VA can get the information required to process your claim. For more information, you can contact us online through Ask VA: https://ask.va.gov/ or call us toll-free at 1-800-827-1000 (TTY: 711).
20 wrz 2024 · Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care. Downloadable PDF. Download VA Form 21-4142 (PDF) Online tool.
23 kwi 2024 · VA Form 21-4142 and Form 21-4142a are medical records release forms that a patient (veteran) must complete in order to release private health information to the Department of Veterans Affairs (VA).
Use this form to provide the name of the provider or facility you have received treatment from to the VA. For more information, contact us at https://ask.va.gov, or call us
The VA Form 21-4142 is known as an Authorization and Consent to Release Information to the Department of Veterans Affairs (VA). The form must be completed in order for the VA to obtain information regarding your medical treatments and history.
1 mar 2018 · Fill out and download VA Form 21-4142 Authorization to Disclose Information to the Department of Veterans Affairs online. Get a PDF or Word version of the blank form, or save the filled form as a ready-to-print PDF.
20 wrz 2024 · Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care. Download VA Form 21-4142 (PDF) Helpful links related to VA Form 21-4142a.
