Va Form 21-4142 - Authorization To Disclose Information To The Department Of Veterans Affairs (Va) Page 3

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OMB Control No. 2900-0001
Respondent Burden: 5 minutes
Expiration Date: 8/31/2017
GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION
TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)
NOTE - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BELOW BEFORE COMPLETING THIS FORM.
INSTRUCTIONS - COMPLETE AND ATTACH THIS FORM WITH A SIGNED VA FORM 21-4142, AUTHORIZATION TO DISCLOSE INFORMATION TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA). IF YOU HAVE MORE THAN THREE PROVIDERS, FILL OUT ADDITIONAL COPIES OF THIS FORM,
AVAILABLE AT
SECTION I - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING
(Type or print)
1. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
SECTION II - MEDICAL PROVIDER INFORMATION
4B. DATE(S) OF TREATMENT:
4A. PROVIDER OR FACILITY NAME
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 4A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
4C. PROVIDER/FACILITY STREET ADDRESS
(Include Area Code)
4D. CITY
4E. STATE AND ZIP CODE
4F. PROVIDER OR FACILITY TELEPHONE NUMBER
5B. DATE(S) OF TREATMENT:
5A. PROVIDER OR FACILITY NAME
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 5A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
5C. PROVIDER/FACILITY STREET ADDRESS
(Include Area Code)
5D. CITY
5E. STATE AND ZIP CODE
5F. PROVIDER OR FACILITY TELEPHONE NUMBER
6B. DATE(S) OF TREATMENT:
6A. PROVIDER OR FACILITY NAME
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 6A)
From:
To:
From:
To:
(Number and street, P.O. or rural route)
6C. PROVIDER/FACILITY STREET ADDRESS
(Include Area Code)
6D. CITY
6E. STATE AND ZIP CODE
6F. PROVIDER OR FACILITY TELEPHONE NUMBER
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in
the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number (SSN) is not furnished completely or accurately, the health
care provider to which this authorization is addressed may not be able to identify and locate your records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing
your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not
result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in
effect prior to January 1, 1975 and still in effect.
RESPONDENT BURDEN: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an
average of 5 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is
displayed. Valid OMB control numbers can be located on the OMB Internet Page at If desired, you may call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.
VA FORM
21-4142a
JUN 2014

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