Va Form 21-4142 - Authorization To Disclose Information To The Department Of Veterans Affairs (Va)

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OMB Control No. 2900-0001

Respondent Burden: 5 minutes

Expiration Date: 8/31/2017

AUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

NOTE - PLEASE READ THE ENTIRE FORM (both pages) BEFORE SIGNING IN ITEM 11 BELOW.

SECTION I - RECORDS TO BE RELEASED TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of: All my medical records; including information related to my ability to

perform tasks of daily living. This includes specific permission to release:

1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including,

but not limited to:

a. Psychological, psychiatric, or other mental impairment(s) excluding "psychotherapy notes" as defined in 45 C.F.R. §164.501,

b. Drug abuse, alcoholism, or other substance abuse,

c. Sickle cell anemia,

d. Records which may indicate the presence of a communicable or non-communicable disease; and tests for or records of

HIV/AIDS,

e. Gene-related impairments (including genetic test results).

2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.

3. Information created within 12 months after the date this authorization is signed in Item 11, as well as past information.

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.

IMPORTANT - In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees charged by a custodian to provide records requested."

SECTION II - VETERAN IDENTIFICATION

(Type or print)

(MM,DD,YYYY)

1. LAST NAME - FIRST NAME - MIDDLE NAME

2. DATE OF BIRTH

3. SOCIAL SECURITY NUMBER/VA FILE NUMBER

SECTION III - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING

(Type or print)

(MM,DD,YYYY)

6. SOCIAL SECURITY NUMBER

4. LAST NAME - FIRST NAME - MIDDLE NAME

5. DATE OF BIRTH

(Include Area Code)

7. STREET ADDRESS

8. CITY, STATE, ZIP CODE

9. TELEPHONE NUMBER

SECTION IV - INFORMATION REGARDING SOURCE OF RECORD(S)

SOURCE OF RECORD(S):

• ALL medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, correctional, addiction treatment,

and VA health care facilities,

• Social workers/rehabilitation counselors,

• Consulting examiners used by VA,

• Employers, insurance companies, workers' compensation programs, and

• Others who may know about my condition (family, neighbors, friends, public officials).

SECTION V - AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE

(If this space is left blank, there is no limitation to records)

10. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE

TO WHOM: The Department of Veterans Affairs (VA).

PURPOSE: Determining my eligibility for benefits, and whether I can manage such benefits.

EXPIRES: This authorization is good for 12 months from the date shown in Item 12.

• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above in Section I.

• I understand that there are some circumstances in which this information may be re-disclosed to other parties (See page 2 for details).

• I may write to VA and my source(s) to revoke this authorization at any time (See page 2 for details).

• VA will give me a copy of this form, if I ask; I may also ask the source(s) to allow me to inspect or get a copy of material to be disclosed.

• I have read both pages of this form and agree to the disclosures above from the types of sources listed. See Patient Acknowledgement on

Page 2.

(Required)

(MM,DD,YYYY) (Required)

11. SIGNATURE OF PERSON AUTHORIZING DISCLOSURE

12. DATE SIGNED

(First, Middle Initial, Last)

(Include Area Code)

13. PRINTED NAME OF PERSON SIGNING

14. TELEPHONE NUMBER

(If other than self, please provide full name, title, organization, city, State, and ZIP code. All court appointments must

15. RELATIONSHIP TO VETERAN/CLAIMANT

include docket number, county, and State)

NOTE: This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical and other information under

P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; 42 U.S.C. §290dd-2; 42 C.F.R. part 2, and State Law.

VA FORM

21-4142

SUPERSEDES VA FORM 21-4142, FEB 2012,

PAGE 1

JUN 2014

WHICH WILL NOT BE USED.