Information Collection

Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a)

IC 228502 under ICR 202009-2900-020 · OMB 2900-0858.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0858 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-4142 Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a) Form
VA Form 21-4142 General Release for Medical Provider Information to Depa 21-4142(11-02-20).pdf www.va.gov/vaforms Form
VA Form 21-4142a General Release for Medical Provider Information to The 21-4142a(11-02-20).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 160 45 CFR 164 45 CFR 2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4142	General Release for Medical Provider Information to Department of Veterans Affairs (VA)	21-4142(11-02-20).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-4142a	General Release for Medical Provider Information to The Department of Veterans Affairs (VA)	21-4142a(11-02-20).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: 58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment Records - VA	FR Citation: 84 FR 4138

Number of Respondents: 127,397	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	127,397	-5,003	132,400
Annual IC Time Burden (Hours)	10,616	-417	11,033
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.