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VA Form 21-4142aPrivate records
General Release for Medical Provider Information to the Department of Veterans Affairs
Identify non-VA medical providers and the records VA should request.
Current official form · Verify on official page · forms-library-2026.07.23 · record a2585a4547a1
When this form is commonly used
Use with Form 21-4142 when asking VA to obtain private treatment records. List provider addresses, treatment dates, and conditions as completely as possible.
Who completes it
Veteran, claimant, or authorized person
What it helps document
- Identifies each provider or facility
- Lists approximate treatment dates
- Links providers to treated conditions
- Helps VA direct its records requests
Common mistakes to avoid
- Omitting provider addresses
- Using overly broad or missing treatment date ranges
- Leaving conditions unidentified
- Submitting it without the related authorization when required
Official VA form information
Use a fresh official copy
Review the current VA instructions before completing the form. The direct action opens the official government PDF or, for DBQs, the official download directory.
Download destination verified July 18, 2026