VA Form 21-4142 is the written authorization that lets the Department of Veterans Affairs collect your medical records from doctors, hospitals, and other providers outside the VA system for use in your disability claim. You fill it out together with its companion, VA Form 21-4142a, and send both to the VA either online at VA.gov or by mail to the Evidence Intake Center in Janesville, Wisconsin. Without your signed authorization, the VA has no legal basis to ask a private provider for your records, because HIPAA blocks the provider from sharing them.
When You Need to File It
You only need this form for records held outside the VA. Treatment you received at VA medical centers or clinics is already accessible to claim reviewers, so no authorization is required for those. Use Form 21-4142 whenever your claim relies on evidence from private physicians, hospitals, labs, mental health or addiction treatment providers, or similar non-VA sources.
The VA’s duty to assist requires the agency to make reasonable efforts to gather evidence supporting your claim, but that duty cannot reach private records until you sign the release.
What Goes on the Form
The form asks for two things: who you are, and who holds the records.
Your Information
Enter your full legal name, Social Security number, date of birth, and VA file number if you have one. Leave the file number blank if none has been assigned; the VA will match your submission by Social Security number. Include a current mailing address and phone number so the VA can reach you if a provider does not respond.
Provider Information
For each source, list the full facility or provider name, complete mailing address, and phone number. “My orthopedist in Dallas” is not enough. If a practice has moved or changed names since your treatment, use whatever contact information is current.
You also need to identify the conditions treated at each location and the range of dates from your first visit through the most recent. Narrow dates and specific conditions keep the request focused and prevent unrelated records from landing in your file.
The Companion Form: 21-4142a
VA Form 21-4142a, the General Release for Medical Provider Information, must be attached to your signed 21-4142. It is where you list the provider names, addresses, treatment date ranges, and conditions that define the scope of each records request. One 21-4142a holds up to five providers. If you saw more, use additional copies.
The entries on the 21-4142a have to match what you wrote on the primary form, including provider names, dates, and conditions. Mismatches cause processing delays. The 21-4142 grants the legal permission; the 21-4142a tells the VA where to send each request and what timeframe to ask about.
Signing
Sign and date the form in the fields provided. Your signature certifies that the information is accurate.
If the veteran cannot sign, a legal guardian, court-appointed representative, or someone holding power of attorney may sign instead. The representative fills in their full name, title, organization, and address in the designated section. Court-appointed representatives also list the docket number, county, and state from their appointment order.
How to Submit It
You have two options, and both forms go in together.
- Online through the VA at va.gov/forms/21-4142/. Online submission gives you faster confirmation of receipt and moves into the queue sooner.
- By mail to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. Use a service with delivery tracking so you have proof of arrival.
Sending the 21-4142 without the 21-4142a, or vice versa, will delay processing.
What Happens Next
Once your authorization arrives, the VA sends each listed provider a copy of your signed release along with a formal records request. Federal law requires the agency to make at least two requests before concluding that further attempts would be unreasonable.1Office of the Law Revision Counsel. 38 US Code 5103A – Duty to Assist Claimants
If a provider still does not respond, the VA will let you know and tell you whether you need to take further steps, such as getting the records yourself and submitting them directly.2Veterans Affairs. VAs Duty to Assist This is a common sticking point. If you already have copies of your private records, you can upload them through the VA portal or mail them to the Evidence Intake Center yourself, which is faster than waiting on a provider and eliminates the risk of a request being ignored.
Expiration and Revocation
A signed 21-4142 is good for 12 months from the date you signed it.3U.S. Department of Veterans Affairs. Authorization to Disclose Information to the Department of Veterans Affairs If your claim is still open after that and the VA needs more records from the same providers, sign and submit a new form.
You can revoke the authorization at any time before it expires, except to the extent a source has already acted on it, such as records the VA already received.4eCFR. Form of Written Consent To revoke, send a written statement to the VA Regional Office handling your claim, or to the Board of Veterans’ Appeals if the claim is on appeal, and send a copy to any provider you no longer want disclosing information.3U.S. Department of Veterans Affairs. Authorization to Disclose Information to the Department of Veterans Affairs Revoking may slow or stall your claim if the VA still needs those records to decide it.
Mistakes That Delay Claims
Incomplete forms are the most common reason claims stall at this stage. The VA will return a form with a missing signature, blank provider fields, or missing dates, and no work happens on your claim in the meantime. Watch for these:
- Provider names or date ranges on the 21-4142a that do not exactly match the 21-4142.
- Provider entries without a full address and phone number. If you are not sure of a current address, call the office or check its website before submitting.
- Date ranges far broader than your actual treatment. A 20-year window for two visits makes the request harder to fill and pulls in records you do not need.
- Submitting the 21-4142 without the 21-4142a. Both are required.
- Letting the 12-month window lapse without filing a fresh authorization while your claim is still pending.