VA Form 21-4142 Authorization to Disclose Information to the Department of Veterans Affairs

VA Form 21-4142 Instructions

By signing the form the veteran authorizes and requests the disclosure of all medical records and gives permission to release the following information:

1. All records regarding medical treatment, hospitalization, and outpatient care for all existing conditions including any mental impairments, records of substance abuse, alcoholism, HIV or AIDS, sickle cell anemia, records indicating the presence of communicable or non-communicable disease, and genetic test results. The veteran's psychotherapy notes may not be disclosed to a third party (as defined in 45 C.F.R. §164.501).
2. Information about how the veteran's condition or impairment affects their ability to participate in everyday tasks.
3. Any medical records created within 12 months after the date VA Form 21-4142 is signed.

Where to Send VA Form 21-4142?

The completed digitally-filed or manually-filed forms should be sent to the nearest VA Regional Office.