Authorization to Disclose Information to the Department of Veterans Affairs

When this form is commonly used

Use when asking VA to obtain records from a private doctor, hospital, employer, insurer, or other non-VA source. VA guidance generally pairs this authorization with Form 21-4142a.

Who completes it

What it helps document

• Provides legal authorization for disclosure
• May cover sensitive treatment information
• Has time-limited authorization language
• Works with provider details on 21-4142a

Common mistakes to avoid

• Submitting 21-4142 without the provider-information form when both are needed
• Missing signature or date
• Providing an incomplete authorization
• Using a version that has expired or been superseded