Fillable VA Form 21-4142 for 2026

VA Form 21-4142 is an authorization that lets the Department of Veterans Affairs request personal information from private doctors, hospitals, and other non-VA healthcare providers. The records may cover medical treatment, hospital stays, psychotherapy, or outpatient care related to your disability or benefits claim.

By signing the form, you give a named provider permission to release relevant records to VA. These records can help VA confirm your condition and decide if you qualify for benefits. Without your signed authorization, VA generally cannot request private medical evidence on your behalf. You may submit the records yourself instead. If VA does not receive needed evidence, it may decide your claim using only the information available.

You may receive this form when VA needs records from a private health care provider or another non-VA source to decide a benefits claim. The VA Form 21-4142 purpose is to let VA request records about medical treatment, hospital stays, psychotherapy, or outpatient care directly from that source.

These records help VA decide if you qualify for benefits, set the correct payment, or assess whether you can manage benefit payments. Your authorization may also waive provider copying fees, which can help VA obtain the needed records without requiring you to collect and send copies yourself.

The U.S. Department of Veterans Affairs (VA) issues VA Form 21-4142. You can get an official blank copy from the VA, or open the blank version already pre-loaded in PDFLeader’s browser-based editor. This means you do not need to download a template from another website before filling it in.

PDFLeader helps you fill out the form and download the completed PDF for your records or next steps. It does not file or submit VA Form 21-4142 to the VA.

After you download the completed form, upload it through VA.gov or another VA online document upload system. VA recommends electronic submission as the fastest method. Make sure you select the related claim or benefit request when the portal asks.

You may also mail the form to the VA Evidence Intake Center or the VA processing center listed in your claim notice. If your notice names a VA regional office, follow those instructions instead. To deliver the form in person, take it to a VA regional office. Keep a copy for your records.

Veterans filing disability compensation or pension claims complete Form VA 21-4142 when they want VA to obtain records from private doctors, hospitals, or clinics. An appointed representative may complete it for the veteran. The person whose medical records are requested must sign the form, or an authorized representative must sign on that person’s behalf.

After the veteran sends the signed form to VA, regional office claims processors and adjudicators use it. They request records from the healthcare providers or facilities listed on the form. VA staff then add the records they receive to the claim file and review them when deciding the claim.

Before signing, check the VA for the latest version and updates to Form VA 21-4142. You can sign it electronically on our platform with a simple electronic signature, then download the completed form. PDFLeader does not support digital signatures or submit forms to the VA. You may also download and print the form, sign it by hand, and follow current VA instructions for submission.

Have the Veteran’s Name, SSN, VA File Number, Date of Birth, service number, and mailing address ready for Section I. If the claimant is not the veteran, Section II asks for the claimant’s name, SSN, and VA file number, if applicable. For Section III, gather details for each medical provider, facility, or person who has relevant records.

In Section IV, identify the information being released, such as hospitalization, treatment, outpatient care, or mental health records. Psychotherapy notes are excluded. Use Box 12 to state any Limitation on Consent. If another person authorizes disclosure, enter that person’s details and relationship in Box 16. Sign and date Section V. The authorization lasts 12 months from the date in Item 14. You do not need to attach the medical records that VA Form 21-4142 authorizes VA to request.

Form VA 21-4142 has no fixed deadline. Submit it with your disability claim or as soon as VA asks for more evidence. Prompt submission can help prevent delays while VA gathers your medical records.

The authorization remains valid for 12 months from the date listed in Item 14. If VA is still gathering records after that period, you will need to complete and sign a new form. Keep a copy for your records.

You do not need Form VA 21-4142 when VA does not need to request records from a non-VA source. This may apply if you received treatment only at VA facilities, your claim relies only on service records or lay evidence, or VA already has the relevant private medical records.

An expired authorization does not remove the need for a new form if VA must request more private records. VA Form 21-4142a lists non-VA providers but does not replace your signed authorization. If a representative submitted only Form VA 21-4142a and VA still needs private records, you may also need to complete Form VA 21-4142.