Va Form 21-4142 - Authorization And Consent To Release Information To The Department Of Veteran Affairs

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OMB Control No. 2900-0001

Respondent Burden: 5 minutes

AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO THE

DEPARTMENT OF VETERANS AFFAIRS (VA)

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. You are not required to respond to a collection of information if this number is not displayed. Valid OMB

control numbers can be located on the OMB Internet Page at If desired, you can call 1-800-827-1000 to

get information on where to send comments or suggestions about this form.

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM, CALL VA TOLL-FREE AT 1-800-827-1000

(TDD 1-800-829-4833 FOR HEARING IMPAIRED).

SECTION I - VETERAN/CLAIMANT IDENTIFICATION

(Type or print)

2. VETERAN'S VA FILE NUMBER

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

(If other than Veteran)

4. VETERAN'S SOCIAL SECURITY NUMBER

3. CLAIMANT'S NAME

LAST NAME, FIRST, MIDDLE