General Release for Medical Provider Information

VA 21-4142a · VA

Companion form to 21-4142 allowing specific medical professionals to release records to VA for claim processing.

Form Details

Total fields: 15
Auto-fillable: 12 (80%)
Time without BeneFill: 10 minutes
Time with BeneFill: 3 minutes
Time saved: 7 minutes
Filled by: patient
Frequency: per incident

Fill this form with BeneFill

Auto-fill 80% of fields from your profile. Save 7 minutes. Download a real PDF.

12 of 15 fields80% auto-filled

Start Filling Upload Your Copy Instead Download blank official form

Where to Submit This Form

🌐

VA.gov

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

Submit with VA 21-4142 as part of your disability claim.

📬

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

📎 Submit together with VA 21-4142 (Authorization to Disclose Information)
📎 Names and addresses of providers whose records you are authorizing release of

Processing Time

Processed with your VA 21-4142. VA will request records within 30-60 days.

What Happens Next

VA will use this general release to obtain private medical records from the providers you listed. You can also submit records yourself for faster processing.

Tips for This Form

✓ This form is a companion to VA 21-4142 — always submit both together
✓ Authorization expires 180 days from signature — submit promptly
✓ Consider obtaining and submitting records yourself to avoid delays

More Veterans Affairs Forms

VA Healthcare Enrollment

VA 10-10EZ · VA

Application for VA health benefits. Requires military service history, current insurance, income/assets, and toxic exposure history.

VA Health Benefits Update

VA 10-10EZR · VA

Health Benefits Update Form for veterans already enrolled in VA health care who need to update personal, insurance, financial, or military service information.

VA Disability Compensation Application

VA 21-526EZ · VA

Application for disability compensation and related benefits for service-connected conditions. Requires linking conditions to military service.

Intent to File a Claim

VA 21-0966 · VA

Preserves the effective date for a VA benefits claim while gathering evidence. Provides 1 year to submit the formal claim.

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.

Statement in Support of PTSD Claim

VA 21-0781 · VA

Statement detailing stressor events related to a PTSD disability compensation claim. Describes incidents during military service.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

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.