List EVERY private provider — VA cannot get records from providers you don't list

This authorization expires 180 days after signing — submit promptly

Consider gathering and submitting records yourself for faster claims processing

Veterans Affairseasy

Authorization to Release Information to VA

VA 21-4142 · VA

Authorization and consent allowing VA to obtain private medical records from non-VA providers for disability claim adjudication.

Form Details

Total fields: 18
Auto-fillable: 14 (78%)
Time without BeneFill: 15 minutes
Time with BeneFill: 5 minutes
Time saved: 10 minutes
Filled by: patient
Frequency: per incident

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Where to Submit This Form

🌐

VA.gov (recommended)

https://www.va.gov/supporting-forms-for-claims/release-information-to-va-form-21-4142/

Submit as part of your disability claim online.

📬

Mail to VA Evidence Intake Center

Department of Veterans Affairs Evidence Intake Center PO Box 4444 Janesville, WI 53547-4444

📠

Fax to VA

Fax: 844-531-7818

Required Attachments

📎 Names and addresses of all private doctors, hospitals, or clinics with relevant records
📎 Approximate dates of treatment
📎 VA 21-4142a (General Release) if authorizing release of specific records

Processing Time

VA will request records directly from providers. Allow 30-60 days for records to be gathered.

What Happens Next

VA will contact each listed provider to request your medical records. You can also submit records yourself for faster processing.

Tips for This Form

✓ List EVERY private provider — VA cannot get records from providers you don't list
✓ This authorization expires 180 days after signing — submit promptly
✓ Consider gathering and submitting records yourself for faster claims processing

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the VA or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.