List private medical providers
Identifies the providers or facilities whose records VA should request.
Authorize private medical-record release
Authorization to Disclose Information to the Department of Veterans Affairs (VA)
Authorizes a private provider or source to release identified health information to VA.
Purpose and use
Use with VA Form 21-4142a when you want VA to request relevant private medical records.
When not to use it
Do not use this form for a different benefit or review path unless current VA instructions identify it for that purpose.
Who completes and signs it?
- Completed by
- veteran or claimant
- Signed by
- veteran or claimant
- Availability
- online and pdf
- Submission
- follow current form instructions
Always start with the official page
Open the current VA version.
Check the revision, instructions, signature requirements, and delivery options immediately before use.
Read before use
Important limitations
- Verify the current revision and submission instructions on the official VA page before signing or sending the form.
- This planner identifies forms that may fit a situation; it does not determine eligibility or filing strategy.
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