The Veterans Benefits Administration (VBA) uses VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), to request private medical records and information regarding the source of records in support of claims for compensation and/or pension benefits. The response helps VA determine whether a source identified by the claimant has pertinent information or records available to consider. VA Form 21-4142 was developed in consultation with the Department of Health and Human Services component responsible for the HIPAA Privacy Rule. It was approved by the Office of Management and Budget (OMB) with the concurrence of HHS.
VA Form 21-4142 is designed specifically to:
Click here to view or fill out VA Form 21-4142.
Fees for Evidence. VA is not authorized to pay a fee for copies of public documents or other evidence from Federal, State or local agencies or private sources. Most custodians of public documents furnish copies to VA free of charge. If payment of a fee is required to obtain a document, VA must advise the claimant that the agency is not authorized to pay the fee and advise him or her how to secure the evidence.
Here are a few important legal points that support use of VA Form 21-4142.
For more information on these seven key points please see the Key Points Explanation webpage.
The HIPAA Privacy Rule, and HHS' December 4, 2002, formal guidance are available at: www.hhs.gov/ocr/hipaa. The preamble of published regulations, which contains important discussions and clarifications of rules, plus responses to public comments, can be found at the Federal Register at www.gpo.gov/fdsys/pkg/FR-2000-12-28/pdf/00-32678.pdf. To find other specific regulations (e.g., 42 CFR Part 2) use: www.gpoaccess.gov/cfr/index.html.
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Last updated October 17, 2017.