If desired you can call 1800827 to get information on where to send comments or suggestions about this form. Va form apr 1998 existing stocks of va form 21 686c, feb 1995, 21 686c will be used. General release for medical provider information to the department of veterans affairs va fillable file type. Va form 214142, authorization to disclose information to. A va form 21526b is known as a veterans supplemental claim for compensation. This week on e bennies was posted return forms 21 4141 and 21 4142 a by 5 may 16.
Va form 21686c declaration of status of dependents. You should only fill out this form if you are requesting vas help in obtaining your. Download a blank fillable va form 214142a general release for medical provider information in pdf format just by clicking the download pdf button. If you use a telecommunications device for the deaf. Va forms 214142 and 214142a veterans benefits network. The advanced tools of the editor will direct you through the editable pdf. Veterans application for compensation and or pension 21 526, supplemental application for compensation 21 526b, authorization to disclose information to the department of veterans affairs 21 4142. If claiming a child in school between the ages of 18 and 23, you must also submit a completed. Ccss first name middle name last name of veteran type or print.
This form may not be executed by any beneficiary recognized as incompetent for va purposes, nor can va accept this form from any beneficiary recognized as incompetent for va purposes. To the department of veterans affairs va instructions complete and attach this form with a signed va form 214142, authorization to disclose information to the department of veterans affairs va. Comments you must sign and va form 21 4142a 15622 federal register vol. This site provides public access to all va forms that are appropriate to be on the web. The family doctor,the hospital and cardiologist my 98 yo. Received a letter from the va requesting a va form 21 4142a. This form is used by the department of veterans affairs in the united states.
Search va forms general release for medical provider information to the department of veterans affairs va fillable file type. 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. Va 214142 2014 2019 printable and fillable, blank pdf. Department of veterans affairs form also known as the general release for medical provider information to the department of veteran affairs va. Fillable va form 214142 free printable pdf sample formswift. Turn them into templates for numerous use, add fillable. You should only fill out this form if you are requesting vas help in obtaining your private nonva medical records. Your vcaa notice may include a copy of va form 214142 andor va form 214142a. If you are looking for help applying for a va benefit for yourself or a loved one, consider. Va form 21p534ez notice to survivor of evidence necessary to.
Hello and welcome back to legal help for veterans va form assistance today were going to be walking through our authorization to disclose information to the department of veterans affairs form also referred to as va form two one four one four two this form will be sent to any client who indicates at any point in the claims process the presence of. Feb 26, 2017 i am slowly getting there i was wondering exactly what the va is after on the medical provider form 21 4142a. I am getting ready to file another claim but am not using the vso i had in jan. This is a onepage form that will be used in conjunction with other claim forms. Download a pdf version of the va form 214142a down below or find it on u. 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. Hello and welcome back to legal help for veterans va form assistance today were going to be walking through our authorization to disclose. Va form 21 4142 authorization to disclose information to va. Aug 31, 2017 download a blank fillable va form 214142a general release for medical provider information in pdf format just by clicking the download pdf button.
Book how to apply for department of veterans affairs benefits for veterans and their survivors. Pdf veterans application for compensation and or pension21526. Va form 21 4142a release for medical provider information to va. Adobe reader or any alternative for windows or macos are required to access and complete fillable content. Fill out the request for employment information in connection with claim for disability benefits online and print it out for free. General release for medical provider information to the department of veterans affairs va va form 214142 and authorization and consent to release information to the department of veterans affairs va form 214142a.
Form 21 4142a is lists of doctors, treatments and times. Va form 21 4142a is used to gather private provider information of the. Form name instrument file url available electronically. Complete and sign va form 214142, authorization to disclose information to the department of veterans affairs va and va form 21 4142a, general release for medical provider information to the department of veterans affairs va, identifying any private medical records you wish va to request for you. Va forms 214142 and va 214142a va disability compensation. Additional va forms 21 4142a can be obtained from the va forms web site at. If va form 21 508 372, certificate of identification, is. Benefit for assisted living, in home care, nursing home expenses pre oct 2018 duration. The responses you submit are considered confidential 38 u. If claiming a child in school between the ages of 18 and 23, you must also submit a completed va form 21674, request for approval of school attendance. I am slowly getting there i was wondering exactly what the va is after on the medical provider form 214142a. Department of veterans affairs, legal, united states federal legal forms and united states legal forms.
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. The family doctor,the hospital and cardiologist my 98 yo grandfather uses i have entered but the dates of treatment would be quite lengthy, is the provider info enough or do they need exact dates for every visit. Use this form if you want to give the department of veterans affairs permission to release your personal beneficiary or claim information to a third party. Va form 214142, authorization to disclose information to the department of veterans affairs va and va form 214142a, general release for medical provider information to the. A va form 21 4142 is a united states department of veteran affairs form used to authorize and provide consent for the release of medical information to the va. If claiming benefits for a seriously disabled helpless child, you must also submit all. Va form 21 4142a fill online, printable, fillable, blank. General release for medical provider information to the department of veterans affairs va va form 214142 and authorization and consent to release information to the department. Health care 8772228387 benefits 800827 tdd hearing impaired 8008294833. The way to complete the online 21 4142 on the internet. And what is the difference between these two forms.
Authorization to disclose information to the department of veterans affairs va fillable file type. Va form 21 4142a pdf fill online, printable, fillable. Oct 06, 2017 your vcaa notice may include a copy of va form 214142 andor va form 214142a. Fill out the request for employment information in connection with claim for disability benefits online. Va form 214142a download fillable pdf or fill online. This is the form that is required to provide permission and consent for the release of any medical information andor treatment received by you to the veterans administration.
The latest edition of the form was released in march 1, 2018 and is available for digital filing. Veterans application for compensation and or pension21526, supplemental application for compensation21526b, authorization to disclose information to the. Department of veterans affairsm211, part iii, subpart iii. Va is asking you to provide the information on this form under 38 u. Received a letter from the va requesting a va form 214142a. Va form 214192 download fillable pdf or fill online. Form ogc consent to release information from va files 35k va form 2122a appointment of individual as claimants representative 375k va form 9 appeal to board of veterans appeals 589k va form 21526 veterans application for compensation andor pension 1,183k va form. Home va commonly used forms va compensation and pension forms va form 214142 authorization for release of information. Va form 214192 download fillable pdf or fill online request. Va form 214142 is of record but a va form 214142a is not develop to the claimant by telephone and record any php source information provided by the claimant on va form 21. A va form 214142 is a united states department of veteran affairs form used to authorize and provide consent for the release of medical information to the va. Download fillable va form 214142 consent to release.
Why would the va need the form if i only see va doctors at a. Va 214142 2014 2019 printable and fillable, blank pdf sample. Authorization to disclose information to the department of veterans affairsva fillable file type. Sections 1705,1710, 1712, and 1722 in order for va to determine your eligibility for medical benefits. Request for employment information in connection with claim for disability benefits. Use this stepbystep guideline to fill out the va form 21 4142 example swiftly and with perfect precision. If claiming dependents,a completed va form 21686c,declaration of status of dependents. This instructional video will help explain and walk you through filling out va form 214124, authorization to disclose information to the department of veterans affairs. Please be sure to sign and date this form in items 23a and 23b. Apply for and manage the va benefits and services youve earned as a veteran, servicemember, or family memberlike health care, disability, education, and more. Approve forms with a legal electronic signature and share them through email, fax or print them out. Va form 214142 is a document used by the department of veterans affairs and is commonly known as an authorization and consent to release information. Va form 21 508 372 is only required in connection with claims for benefits withheld under 38 u.
Benefit from a electronic solution to create, edit and sign documents in pdf or word format on the web. This week on e bennies was posted return forms 214141 and 214142 a by 5 may 16. Va form 21 4142 a keyword found websites listing keyword. For free help in completing this form, call va tollfree at 1800827. Not knowing what to make of it other then an authorization to release my medical records to the va. General release for medical provider information to the. Form va 214142 authorization and consent to release. Please be sure to sign and date this form in items 21a and 21b. If you use a telecommunications device for the deaf tdd, the federal number is 711. Complete documents electronically utilizing pdf or word format. Make them reusable by generating templates, include and fill out fillable fields.
It will allow the department of veterans affairs to gain more information about the veteran to determine. Fillable va form 21526b free printable pdf sample formswift. Sep 24, 2015 va form 214142 is of record but a va form 214142a is not develop to the claimant by telephone and record any php source information provided by the claimant on va form 21 4142a, or if unable to reach the claimant via telephone, send a development letter to the claimant requesting the return of a completed. Va form 21 4142, authorization to disclose information to the department of veterans affairs va and va form 21 4142a, general release for medical provider information to the department of veterans affairs va, in order for va to obtain your treatment records. Notice to department of veterans affairs of veteran or beneficiary incarcerated in penal institution fillable 362018. Federal register agency information collection activity. If va form 21508 372, certificate of identification, is. Va form 214142a download fillable pdf or fill online general. Va form 214142a us department of veterans affairs va form 214142a.