Form VA 21-4142

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Get your Form VA 21-4142 in 3 easy steps

  • 01 Fill and edit template
  • 02 Sign it online
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What is Form VA 21-4142?

The VA form 21 4142 is also known as the Authorization and Consent to Release Information to the Department of Veterans Affairs. This document is vital for disabled veterans who need to receive treatment from the government. The Department of Veterans Affairs created the form to be able to obtain and record information on veterans who require medical treatment.

If a veteran wants to receive free care this form must be filled in the first place. It is an agreement to provide medical records to the VA. The department receives consent to check records on medical treatment, psychotherapy, hospitalization, and outpatient care.

Fill out the form to provide access to the medical records to the VA department. They will decide how much information they need and reveal it to you. You can also contact the department in advance and make sure that they receive only the data you allow access to.  You also have to share the information on the medical establishment and physician that provides you care.

VA 21-4142 on PDFLiner

What I need the Form VA 21-4142 for?

  • Veterans of the US army need VA form 21-4142 to receive free medical treatment based on the VA department’s decision. This document helps to record all the procedures the veteran has to go through, and the information will be saved on the official level;
  • The VA department requires the records on the medical treatment that veterans receive from the government to cover expenses and decide whether they can pay for the case or not. These records will be checked and officials will make decisions based on them. If the case matches the demands, the officials will cover full or part of the expenses to the medical establishment.

How to Fill Out Form VA 21-4142?

If you are looking for this document you may begin by checking the website of the Veterans Affairs department. You will see a brief description of the document, including its major purpose. There is also a PDF document you can download on your devices. However, the VA form 21 4142 fillable version is only available on PDF editors. If you want to complete this document while you are online, it is better to use PDFLiner.

This editor has a wide range of tools. Apart from the guide to the form, you will be able to enter it and fill everything online. You may later send the document to the department or to the witness via email. Besides, you can always save the form on your device or print it. Here is what you need to include in VA form 21-4142 PDF:

  1. Provide information about yourself, including the name, file number, name of the claimant if it is not you, and SS number of the veteran and the claimant if they are different. Name the relations between the veteran and the claimant. If it is you, just put their “self”;
  2. Provide information on the physician and hospital you receive treatment, including the name and address, dates when the treatment was received, and condition you received the treatment for;
  3. Put the signature and date. You have to provide your mailing address and phone number so you can be easily reached by the VA department. Ask witnesses to sign the paper.

VA 21-4142 on PDFLiner

Organizations that work with Form VA 21-4142

  • Department of Veterans Affairs in the US;
  • Medical establishments.

Form Versions

2004 Fillable Form VA 21-4142 (2004) Fill Out Form
Fillable online Form VA 21-4142
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