Get Va 21-4142a 2014-2025

The VA 21-4142a form serves as a general release for medical provider information to the Department of Veterans Affairs. This guide will provide clear, step-by-step instructions for filling out the form online, ensuring users understand each component.

Follow the steps to fill out the VA 21-4142a form with ease.

1. Press the ‘Get Form’ button to access the VA 21-4142a document. This will allow you to open the form in your preferred editor.
2. In Section I, provide your identification details as the patient. Enter your last name, first name, and middle name. Next, include your social security number and VA file number.
3. Proceed to Section II, where you will input medical provider information. Start with the first provider or facility's name in field 4A and specify the dates of treatment in field 4B. Make sure to include the full time period (month/year) of treatment.
4. Fill out the provider or facility's street address in field 4C, including the number, street, P.O. box, or rural route. Continue by providing the city in field 4D, the state in field 4E, and the zip code.
5. Repeat the process for additional medical providers in fields 5A to 6F as necessary. For each, ensure that you include the provider or facility's name, treatment dates, address, and telephone number.
6. After completing all required fields, review your form for accuracy. Once you are sure all information is correct, proceed to save your changes, download the form, or print it for submission.

Complete the VA 21-4142a form online today to ensure a smooth process with your medical provider information.