Search results with tag "21 4142"
VA Form 21-526EZ
www.vba.va.gov• Complete and sign VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA) and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), identifying any …
(DO NOT WRITE IN THIS SPACE) AUTHORIZATION TO …
www.vba.va.govauthorization to disclose information to the department of veterans affairs (va) section iii - information regarding source of record(s) va form jul 2021 21-4142€ supersedes va form 21-4142, mar 2018. omb control no. 2900-0858 respondent burden: 5 minutes expiration date: 07/31/2024. page 1. instructions:
YOUR RIGHTS TO SEEK FURTHER REVIEW OF OUR …
www.va.govwant VA to help you gather records, complete and return the appropriate Release of Information Form: 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA) or 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). For a . Higher-Level Review, complete
STATEMENT IN SUPPORT OF CLAIM FOR SERVICE …
www.vba.va.govthe treatment records, complete VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If you confided in roommates, family members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement concerning their knowledge of the incident.