Va Form 21 4142 Printable DEPARTMENT OF VETERANS AFFAIRS VA SUPERSEDES VA FORM 21 4142 MAR 2018 OMB Control No 2900 0858 Respondent Burden 5 minutes Expiration Date 07 31 2024 If completed by hand print the information requested in ink neatly and legibly and insert one letter per box to help expedite processing of the form
SECTION II PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING If other than veteran OMB Control No 2900 0858 Respondent Burden 5 minutes Expiration Date 07 31 2024 SUPERSEDES VA FORM 21 4142a MAR 2018 VA FORM JUL 2021 21 4142a Page 1 GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS VA 1 Get VA Form 21 4142 to download Submit a lay or witness statement to support a VA claim VA Form 21 10210 Use this form to submit a formal statement to support your VA claim or the claim of another Veteran or eligible family member People also sometimes call this statement a buddy statement You can submit this form online or by mail
Va Form 21 4142 Printable
Va Form 21 4142 Printable
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VA Form 21 4142A General Release For Medical Provider Information To The Department Of
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VA Form 21 4142 A 4 Step Quick Guide For Veterans
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You ll need to submit or identify medical evidence that documents the diagnosis and severity of your claimed condition If you have qualifying military service we automatically assume or presume that your service caused your condition 1 18 VA Form 21 4142 Authorization for Release of Information Authorization for Release of Information Effective date July 2021 Downloads pdf VA Form 21 4142 Release of Information pdf This page was Helpful Not Helpful VA Form 21 4138 Statement in Support of Claim VA Form 21 8940 Application for Increased Compensation due
Complete VA Form 21 4142 Authorization to Disclose Information to the Department of Veterans Affairs VA and VA For 21 4142a General Release for Medical Provider Information to the Department of Veterans Affairs VA submit completed forms with your claim and VA will attempt to obtain your records through our Private Medical Records contract VA Form 21 4142 Authorization to Disclose Information to the Department of Veterans Affairs VA PDF legally permits you to make the necessary disclosures of information consistent with applicable laws including the Health Insurance Portability and Accountability Act HIPAA and the Substance Abuse Act 1
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Va Form 4142A Form 21 4142 Authorization And Consent To Release
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Va Form 4142A Form 21 4142 Authorization And Consent To Release
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VA Form 21 4142A Printable Fillable In PDF VA Form
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VA Form 21 4142 also known as the Authorization to Disclose Information to the VA is a form that permits the release of a veteran s records to the VA from non VA sources including hospitals or private doctor s offices For example veterans may wish to release personal information from outpatient care medical treatment psychotherapy or hospitalizations DEPARTMENT OF VETERANS AFFAIRS VA VA FORM FEB 2012 21 4142 Existing stocks of the VA Form 21 4142 JAN 2011 will be used 1 LAST NAME FIRST NAME MIDDLE NAME OF VETERAN Type or print 4 CLAIMANT S NAME If other than veteran LAST NAME FIRST MIDDLE 6 RELATIONSHIP OF CLAIMANT TO VETERAN 8A
VA Form 21 4142 is a document used by the Department of Veterans Affairs and is commonly known as an Authorization and Consent to Release Information This is a document that requires a veteran to provide his or her consent so that the VA may obtain the necessary information regarding their medical history and any treatments they may have received 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 VA FORM JUN 2014 21 4142 SUPERSEDES VA FORM 21 4142 FEB 2012 WHICH WILL NOT BE USED 1 LAST NAME FIRST NAME MIDDLE NAME Type or print 10
Fillable Va Form 21 4142a General Release For Medical Provider Information Printable Pdf Download
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VA Form 21 4142A Fill Out Sign Online And Download Fillable PDF Templateroller
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https://www.vba.va.gov/pubs/forms/VBA-21-4142-ARE.pdf
DEPARTMENT OF VETERANS AFFAIRS VA SUPERSEDES VA FORM 21 4142 MAR 2018 OMB Control No 2900 0858 Respondent Burden 5 minutes Expiration Date 07 31 2024 If completed by hand print the information requested in ink neatly and legibly and insert one letter per box to help expedite processing of the form
https://www.vba.va.gov/pubs/forms/VBA-21-4142a-ARE.pdf
SECTION II PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING If other than veteran OMB Control No 2900 0858 Respondent Burden 5 minutes Expiration Date 07 31 2024 SUPERSEDES VA FORM 21 4142a MAR 2018 VA FORM JUL 2021 21 4142a Page 1 GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS VA 1
VA Form 21 4142 Authorization To Disclose Information To The Department Of Veterans Affairs
Fillable Va Form 21 4142a General Release For Medical Provider Information Printable Pdf Download
Fill Free Fillable VBA 21 4142 ARE VA Form 21 4142 PDF Form
VA Form 21 4142 A 4 Step Quick Guide For Veterans
Va Form 4142A Form 21 4142 Authorization And Consent To Release
VA Form 21 4142 A 4 Step Quick Guide For Veterans
VA Form 21 4142 A 4 Step Quick Guide For Veterans
VA Form 21 4142 Fill Out Sign Online And Download Fillable PDF Templateroller
Va Form 4142A Form 21 4142 Authorization And Consent To Release
Va Form 21 4142 Fill Out And Sign Printable PDF Template SignNow
Va Form 21 4142 Printable - Complete VA Form 21 4142 Authorization to Disclose Information to the Department of Veterans Affairs VA and VA For 21 4142a General Release for Medical Provider Information to the Department of Veterans Affairs VA submit completed forms with your claim and VA will attempt to obtain your records through our Private Medical Records contract
