Va Form 21-4142a - General Release For Medical Provider Information

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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)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

1. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN

SECTION II - MEDICAL PROVIDER INFORMATION

4B. DATE(S) OF TREATMENT:

(Include the time period (month/day/year)

4A. PROVIDER OR FACILITY NAME

for the treatment by the provider listed in

Item 4A)

From:

To:

From:

To:

4C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)

4D. CITY

4F. PROVIDER OR FACILITY TELEPHONE NUMBER (Include Area Code)

4E. STATE AND ZIP CODE

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)

To:

From:

To:

5C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)

5D. CITY

5F. PROVIDER OR FACILITY TELEPHONE NUMBER (Include Area Code)

5E. STATE AND ZIP CODE

6B. DATE(S) OF TREATMENT:

(Include the time period (month/day/year)

6A. PROVIDER OR FACILITY NAME

for the treatment by the provider listed in

Item 6A)

To:

From:

To:

6C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)

6D. CITY

6E. STATE AND ZIP CODE

6F. PROVIDER OR FACILITY TELEPHONE NUMBER (Include Area Code)

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