Transcription of (DO NOT WRITE IN THIS SPACE) AUTHORIZATION TO …
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(DO NOT WRITE IN THIS SPACE) AUTHORIZATION TO …
SECTION I - VETERAN IDENTIFICATION INFORMATIONAUTHORIZATION TO DISCLOSE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA) SECTION III - INFORMATION REGARDING SOURCE OF RECORD(S) VA FORM JUL 202121-4142 SUPERSEDES VA FORM 21-4142, MAR 2018. OMB Control No. 2900-0858 Respondent Burden: 5 minutes Expiration Date: 07/31/2024 PAGE 1 INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to provide your written AUTHORIZATION to obtain your treatment records, so the VA can get the information required to process your claim. For more information, contact us at , or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the relaynumber is 711.
practicable, provide for the option of electronic maintenance, submission of disclosure of information and for the use and acceptance of electronic signatures. GPEA states that electronic records submitted or maintained in accordance with the procedures developed by OMB, or electronic signature or other forms of electronic
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