VA 21-4142 2012 free printable template

This is not required by VA but may be required by the source of the information. 12B. DATE VA FORM 21-4142 FEB 2012 PAGE 2. COMMENTS YOU MUST SIGN AND DATE THIS FORM ON PAGE 2 AND CHECK THE APPROPRIATE BLOCK IN ITEM 10C. VA FORM FEB 2012 21-4142 Existing stocks of the VA Form 21-4142 JAN 2011 will be used. PAGE 1 SECTION III - CONSENT TO RELEASE INFORMATION READ ALL PARAGRAPHS CAREFULLY BEFORE SIGNING. YOU MUST CHECK THE APPROPRIATE STATEMENT UNDERLINED IN PARENTHESES IN PARAGRAPH 10C. OMB...

How to fill out VA 21-4142

How to fill out VA 21-4142

1. Begin by downloading the VA Form 21-4142 from the VA website.
2. Enter your personal information at the top of the form, including your name, address, and Social Security number.
3. In the next section, specify the name and address of the person or organization you are authorizing to release your medical records.
4. Clearly describe the information you are requesting and the dates for which the records are relevant.
5. Sign and date the form to authorize the release of the information.
6. Make a copy of the completed form for your records before submitting it to the VA or the medical provider.

Who needs VA 21-4142?

1. Veterans seeking to obtain their medical records or treatment information from healthcare providers.
2. Individuals applying for disability benefits, pensions, or other services requiring medical documentation.

• Who needs a VA Form 21-4142?
• What is fillable VA Form 21-4142 for?
• Is VA Form 21-4142 accompanied by other forms?
• • When is VA Form 21-4142 due?
  • How do I fill out VA Form 21-4142?
  • Where do I send VA Form 21-4142?

Who needs a VA Form 21-4142?

A VA Form 21-4142 is known as an Authorization and Consent to Release Information to the US Department of Veteran Affairs. It is filled out by the citizens who are going to claim a disability. The form VA 21-4142 will be used by the Department of Veteran Affairs for processing and reviewing disability or medical claims filed by US Army veterans.

What is fillable VA Form 21-4142 for?

The completion of the Authorization and Consent to Release Information form provides permission to obtain medical records from the claimant physician or healthcare provider to the Veteran’s Administration.

Is VA Form 21-4142 accompanied by other forms?

The VA 21-4142 fillable form is used as a supplement itself, preceding submission of a claim for VA benefits.

When is VA Form 21-4142 due?

The VA 21 4142 Authorization form is in effect for 12 months. However, the Authorization and Consent can be revoked by the claimant when considered necessary. If the revocation doesn’t happen, the authorization will automatically expire in 12 months after the date indicated in the form.

How do I fill out VA Form 21-4142?

The information to provide on the printable VA Form 21-4142 must clearly indicate:

• Veteran/Claimant Identification (name, date of birth, SSN)
• Source of Pertinent Information (identification of the medical treatment provider and its contact information, dates of treatment, disabilities)
• Consent to Release Information (signature, mailing address, date, etc.)

Where do I send VA Form 21-4142?

The properly filled out VA 21-4142 Form must be submitted to the local VA office.

Instructions and Help about VA 21-4142

Laws dot-com legal forms guide a VA Form 21 – 41 42 is a United States Department of Veteran Affairs form used to authorize and provide consent for the release of medical information to the VA this form must be on file before Veterans Affairs can review any medical or disability claims the VA Form 21 – 41 42 is available on the Veterans Affairs documentation website or can be supplied through a local Veterans Affairs office the first section is used for general identification information boxes 1 2 camp; 4 are to be filled out with the veterans name file number and social security number these boxes must be filled in if a claimant other than the veteran is seeking benefits on behalf of the veteran they must provide their name relationship and social security number in boxes 3 5 camp; 6 in section 2 you must identify all sources of medical information for which you are allowing Veterans Affairs to have you must include the name and addresses for all offices for which your medical or disability claim involves you must also include the dates and conditions or illnesses for which you were treated inbox aid provide any additional comments about your consent that will be helpful for Veterans Affairs to seek your medical history and to view them section 3 provides all the important privacy information that the Department of Veterans Affairs will be held to read all the information and check the authorization box in box 9 see in box 10 the veteran the claimant or a legal representative must certify with their signature their consent of the VA form 21 – 41 42 provide your contact information including address and phone numbers this is important as Veterans Affairs may need to contact you in regard to this form and to further obtain your consent for additional information they need for processing your claims in box 11 it is important that you have a witness sign and date the form while this is not necessary for all medical records Veterans Affairs may need a witness statement when seeking some of your records once completed your VA Form 21 – 41 42 is ready for submission to Veterans Affairs keep a copy on record as you may need to submit an additional consent forms if you make additional claims to watch more videos please make sure to visit laws dot-com

People Also Ask about

How long is VA form 21 4142 good for?

Finally, veterans must sign and date VA Form 21 4142, including applicable limitations. In addition, if the signature is not from the veteran or claimant, they must include their relationship with the client. Once signed, the form permits the VA to obtain your medical records for 12 months.

Why does the VA need form 21 4192?

Use VA Form 21-4192 if you're a Veteran and you need your most recent employer to send us information so you can apply for Individual Unemployability disability benefits. Your most recent employer must complete and submit this form.

What is the difference between from 21 4142 and 21-4142a?

VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA. Without this information, determination of entitlement would not be possible.

What is the purpose of VA form 21 4142?

When to use this form. Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.

Should I fill out a VA form 21 4142?

YOU SHOULD NOT COMPLETE THIS FORM UNLESS YOU WANT THE VA TO OBTAIN PRIVATE TREATMENT RECORDS ON YOUR BEHALF. IF YOU HAVE ALREADY PROVIDED THESE RECORDS OR INTEND TO OBTAIN THEM YOURSELF, THERE IS NO NEED TO FILL OUT THIS FORM. DOING SO WILL LENGTHEN YOUR CLAIM PROCESSING TIME.

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What is VA 21-4142?

VA Form 21-4142 is a form used by veterans to authorize the release of private medical information to the Department of Veterans Affairs (VA) for the purpose of obtaining benefits.

Who is required to file VA 21-4142?

Veterans applying for disability compensation or any other VA benefits that require medical evidence may be required to file VA Form 21-4142.

How to fill out VA 21-4142?

To fill out VA Form 21-4142, one must provide personal information such as name, address, and Social Security number, along with details of the medical provider from whom the information is requested, and sign the form to authorize the release of information.

What is the purpose of VA 21-4142?

The purpose of VA Form 21-4142 is to facilitate the collection of medical records from private healthcare providers that are necessary for the VA to process a veteran's claim for benefits.

What information must be reported on VA 21-4142?

On VA Form 21-4142, the veteran must report their personal information, the name and address of the healthcare provider, the dates of treatment, and any specific information being requested.