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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. VA forms are available at For mailing information see page II - PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING (If other than veteran)1.
SECTION V- AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO VA AND SIGNATURE 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 14.
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