Fillable VA Form 21-4142a (2026)

VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs, identifies non-VA health care providers that may hold records about your condition. You list each private doctor, hospital, or clinic, along with its address and your treatment dates. The VA uses these details to locate records that may support your disability or benefits claim.

VA forms 21-4142 and 21-4142a work together. Form 21-4142 gives written authorization to release your medical records, while Form 21-4142a tells the VA where to request them. You generally need to complete both forms so the VA can obtain private treatment records. These records help claims staff review your medical history and make a decision on your claim.

You use VA Form 21-4142a when a VA benefits claim depends on records from a private doctor, hospital, clinic, or other non-VA provider. You list each provider’s name and address, along with the dates of treatment, so VA knows where to request supporting medical records.

The form is often included with a disability claim, such as VA Form 21-526, and works with VA Form 21-4142. VA Form 21-4142 gives permission to release the records, while VA Form 21-4142a identifies the providers that hold them. These records help VA decide if you qualify for benefits.

The U.S. Department of Veterans Affairs issues VA Form 21-4142a through its Veterans Benefits Administration. You can also get a blank copy from PDFLeader. The form is preloaded in our browser-based editor, so you do not need to find and download a separate template.

PDFLeader lets you fill out the form and download the completed copy for future use. Our platform does not file or submit VA Form 21-4142a to the Department of Veterans Affairs. Follow the VA Form 21-4142a instructions to learn how and where to send it.

After you complete and download the form, you can send it to VA online or by mail. For online delivery, use VA’s online authorization tool, which sends your information directly to VA. Follow the tool’s process rather than mailing another copy unless VA asks for one.

For mail delivery, send the completed VA Form 21-4142a PDF to the Department of Veterans Affairs, Evidence Intake Center. Keep a copy for your records and include any related release documents VA requires.

Veterans who are applying for disability compensation or pension may need to complete this form. An authorized representative or claimant may also complete it for the veteran. If VA needs records from a private doctor, hospital, or other non-VA source, the person completing VA Form 21-4142 and 21-4142a must list each provider’s name, address, and treatment dates.

Afterward, VA claims-processing staff use the information to request the listed medical records. Vendors working under VA’s Private Medical Records contract may contact the providers and retrieve the records. VA then adds the records to the veteran’s claims file and reviews them when deciding benefit eligibility.

No signature is needed on VA Form 21-4142a itself. You must attach it to a signed and dated VA Form 21-4142, which authorizes the release of your medical records. With PDFLeader, you can fill out and download the completed form in your browser, but you must submit it elsewhere. Check the latest VA Form 21-4142a instructions before sending VA Form 21-4142 and 21-4142a to the VA.

Have the veteran/beneficiary's name, Social Security number, VA file number, date of birth, and service number, if applicable. For each medical provider, prepare the provider or facility name, complete address, dates of treatment, and conditions treated. Use your medical records, bills, or appointment notes to confirm these details, but you do not need to attach them unless VA asks for them.

Submit the 21-4142a VA Form with a completed and signed VA Form 21-4142. VA needs the signed release before it can request private medical records from the providers listed on VA 21-4142a.

VA Form 21-4142a has no fixed due date. Submit it when the VA requests it, often after you file a disability claim. You may also submit it with your claim if private, non-VA medical records support your case.

Send the form as soon as you can, ideally with your claim, to help prevent processing delays. Your authorization remains valid for 12 months from the date you sign it. After that period ends, you must complete and sign a new form if the VA still needs access to the records.

If you already have your private medical records and submit them directly to VA, you do not need to complete VA Form 21-4142a. You may also skip it if you plan to obtain the records and send them to VA yourself.

Your response is voluntary, and there is no penalty for not submitting the form. However, without the required authorization, VA will not request records from a private medical provider on your behalf. No dollar threshold affects this choice.