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Private Provider Information

HIPAA Compliance

How VA Form 21-4142 Meets Requirements for Authorization to Disclose Information

The following language is extracted from the VA Form 21-4142.

SECTION I - RECORDS TO BE RELEASED TO THE DEPARTMENT OF VETERANS AFFAIRS (VA)

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of: All my medical records; including information related to my ability to perform tasks of daily living. This includes specific permission to release:

  1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, but not limited to:
    1. Psychological, psychiatric, or other mental impairment(s) excluding "psychotherapy notes" as defined in 45 CFR 164.501,
    2. Drug abuse, alcoholism, or other substance abuse,
    3. Sickle cell anemia,
    4. Records which may indicate the presence of a communicable or non-communicable disease; and tests for or records of HIV/AIDS,
    5. Gene-related impairments (including genetic test results).
  2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
  3. Information created within 12 months after the date this authorization is signed, as well as past information.

IMPORTANT: In accordance with 38 C.F.R. §3.159(c), "VA will not pay any fees charged by a custodian to provide records requested."

SECTION V - AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE

IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):

TO WHOM: The Department of Veterans Affairs (VA).

PURPOSE: Determining my eligibility for benefits, and whether I can manage such benefits.

EXPIRES: This authorization is good for 12 months from the date shown in Item 12.

  • I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above in Section I.
  • I understand that there are some circumstances in which this information may be re-disclosed to other parties (See page 2 for details).
  • I may write to VA and my source(s) to revoke this authorization at any time (See page 2 for details).
  • VA will give me a copy of this form, if I ask; I may also ask the source(s) to allow me to inspect or get a copy of material to be disclosed.
  • I have read both pages of this form and agree to the disclosures above from the types of sources listed.

NOTE: This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical and other information under P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; 42 U.S.C. §290dd-2; 42 C.F.R. part 2, and State Law.

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.