Save Time with VA Form 21-4142

What is VA Form 21-4142 and How to Fill it Out Correctly

Veterans need to submit medical evidence to support their claims for service-connected disabilities or other VA benefits. In some cases, you may have to go through a lengthy and complex treatment and address several different specialists and treatment facilities. 

To collect all these medical documents and evidence, you will have to request all the data about previous hospitalizations, psychotherapy, or any other treatments connected to your service-related disability. 

As a rule, once you want to obtain a copy of your medical records, whether from a private specialist or a medical facility, you will be charged a fee that covers the cost of searching, producing, and posting those records to you.

VA Form 21-4142 was designed precisely for such cases, as it allows the VA to gather medical records or other information about a Veteran’s health, releasing them from the necessity of requesting those records and paying the fees themselves.

This form is not mandatory. If you have already provided those records to support your case or want to obtain the data on your own, you don’t need to fill out VA Form 21-4142.

However, VA Form 21-4142 was introduced as a service to Veterans, a means to assist them in their VA benefits claim process. 

VCU does our best to help Veterans and their loved ones make informed decisions about their VA disability claims. We believe that it is vital to be aware of such tools as VA Form 21-4142, even though it is not considered an integral part of the VA benefits claim process for every Veteran.

That is why in this article we shall provide a thorough step-by-step guide to filling out the VA Form 21-4142 and some tips to ensure that you are not missing out on the tools that can help you speed up and facilitate the process of receiving your well-deserved benefits.

The Structure of VA Form 21-4142

Before getting down to the procedure of filling out and submitting VA Form 21-4142, here is a brief overview of the form itself and its main sections. It will help you understand what kind of information you will have to provide to fill out VA Form 21-4142 correctly and make the overall process much easier.

Here is a brief overview of the form’s sections and their explanations:


    1. Veteran Identification Information
      This section collects general information about you, such as your full name, date of birth, social security number, VA file number (if available), and contact information.

    1. Patient Identification for Records VA is Requesting (if other than Veteran)
      If someone is completing the form on your behalf, this section captures the authorized representative’s information – their name, relationship to you, and contact details.

    1. Information Regarding the Source of Record(s)
      Here, you provide details about the healthcare providers, facilities, or organizations that have the requested records. This includes the name, address, and contact information of the provider or facility. 

    1. Records to be Released to the Department of Veterans Affairs (VA)
      Here, you will specify the type of information you are authorizing to release. This could include medical records, treatment records, test results, and any other relevant documents. You need to describe the information as accurately as possible to ensure the correct records are released.

    1. Authorization and Consent to Release Information to VA and Signature 
      This section limits to whom you authorize the release of your medical information (The Department of Veterans Affairs (VA). If you leave this space blank, legally there won`t be a limitation to the released medical records. By signing this document, you grant VA access to your private medical records for 12 months from the date of your signature. However, you still have the right to revoke this authorization at any moment.

How to Fill Out and Submit VA Form 21-4142

You can always get the most recent version of VA Form 21-4142 from the official website of the U.S. Department of Veterans Affairs. You can complete the form online and submit it electronically, or do it by hand and then send the form by mail or bring it to your local VA Regional Office. 

However, practice shows that electronic submission significantly speeds up the process.

Now, let’s break down each section of the VA Form 21-4142, so you can fill it up correctly without bogging down on the bureaucratic language and confusing wording of such documents.

Sections I and II: Identification Information

We decided to combine these two sections in our guide as they require the same type of information:


    • Name 

    • Social Security Number 

    • VA File Number

    • Date of Birth

    • Veteran’s Service Number (if applicable) 

    • Mailing Address

    • Phone Number

    • Email Address

As we have already explained, you fill out Section I if you are the Veteran who gives authorization to fetch the required medical records. If the information is requested on behalf of the Veteran, the authorized representative fills up Section II, specifying their relationship to the Veteran and adding their own VA file number (if applicable).

Section III: Information Regarding the Source of Record(s)

Now you need to provide detailed information about the sources that can provide VA with the necessary medical information.

Here you need to include:


    • Clinics, labs, hospitals, physicians, and psychologists, including VA healthcare facilities, that you addressed with your service-related medical condition. Don’t forget to mention rehabilitation counselors and social workers who were involved in your treatment as well.

    • Facilities for mental health, addiction, and correctional treatment

    • VA-related consulting examiners

    • Workers’ compensation programs, insurance companies, employers, and public officials, as well as all other people or organizations that are aware of your condition and can provide relevant information.

Note that the current version of VA Form 21-4142 provides space for only five such sources. However, if you have more, you can photocopy the form and continue filling it up, or even write information about additional courses on a separate sheet of paper.

As for the dates of treatment, you are not obliged to give the exact dates if you cannot remember them. Still, try to provide a more or less accurate range to make the data search easier and faster.

Another important thing to remember is that most medical facilities clean their records once every 7–10 years. So, if you provide data about the event that happened a long time ago, there is a chance that the information may already be unavailable.

 Section IV: Records to be Released to the Department of Veterans Affairs (VA)

This section will give the VA access to information like:


    • Conclusions regarding your ability to work or perform daily activities

    • Medical data on treatment for your service-related condition, including hospitalization and outpatient care

    • All your medical data, which may occur within 12 months after signing the form, unless you revoke this authorization at some point

Section V: Authorization and Consent to Release Information to VA and Signature

With this section, the VA not only ensures your permission to fetch the medical data about your service-related condition but also lets you set limitations for the disclosure and use of this data.

Remember that signing VA Form 21-4142 is a legally significant action that carries specific implications and responsibilities. When you or an authorized representative sign this form, you are providing consent and authorization for the release of your medical records or other specified information to the designated recipient.

Reach Out to VCU Experts Today Who Can Help!

 It is only natural to feel a bit lost in the sea of forms and paperwork. That is why you should not hesitate to seek professional assistance that will guide you through the process and help you achieve your goals faster and easier. Schedule a call with a VCU Veterans Specialist. Give yourself the peace of mind that you’re on the right track and will soon receive the maximum VA disability benefits you deserve.

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