Va form 214142 is a fairly straightforward form, requiring the veterans name, social security number, and va file number. Statement in support of claim how to use it to win your va claim duration. Va forms 214142 and va 214142a va disability compensation. Make them reusable by making templates, add and fill out fillable fields. Additional va forms 21 4142a can be obtained from the va forms web site at. A va form 21 4142 is a united states department of veteran affairs form used to authorize and provide consent for the release of medical information to the va. Please be sure to sign and date this form in items 21a and 21b. Look at the table below to find out which parts of va form 21526 you should use to apply for.
I may also ask the sources to allow me to inspect or get a copy of material to be disclosed. Section ii patient identification for records va is requesting if other than veteran 9b. Section iii patient identification for records va is requesting if other than veteran section i records to be released to the. This is the form we use to request private treatment reports from doctors and hospitals. You can provide this authorization by signing va form 214142. Look at the table below to find out which parts of va form 21526 you should use to apply for different benefits. Additional 214142 forms can be obtained from the va forms web site at. Va form 21 4142, authorization and consent to release information to the.
If va form 214142 expires before va can obtain the phpsvet center records, request the veteran provide va with an updated va form 214142. In box va form 214142, the veteran, the claimant, or a legal representative must certify with their signature their va form 214142 of the va form therefore, they could only grant one, as that would be pyramiding for both. If desired, you can call 1800827 to get information on. This instructional video will help explain and walk you through filling out va form 21 4124, authorization to disclose information to the department of veterans affairs. 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, in order for va to obtain your treatment records. It can be used for many different situations, so just a blanket example of a completed form would not necessarily apply to your situation. M211mr part i manual for disability compensation veterans. Use va form 21526 to apply for compensation andor pension benefits.
If the veteran has been treated in a private medical facility and those records are relevant to the claim, complete a. The family doctor,the hospital and cardiologist my 98 yo grandfather uses i have entered but the dates of treatment would be quite lengthy, is the provider info enough or do they need exact dates for every visit. Book how to apply for department of veterans affairs benefits for veterans and their survivors. Include the time period mmddyyyy for the treatment by the provider listed in item 9a va form mar 2018. Fill out, securely sign, print or email your va form 21 4142 example instantly with signnow. General release for medical provider information to the. Form 21 4142a is lists of doctors, treatments and times. Search va forms authorization to disclose information to the department of veterans affairsva fillable file type. A statement in support of claim for service connection for posttraumatic stress disorder secondary to personal assault va form 210781a. If you are looking for help applying for a va benefit for yourself or a loved one, consider purchasing our new book how to apply for department of veterans affairs benefits for veterans and their survivors published in 2020. Jan 09, 2018 this instructional video will help explain and walk you through filling out va form 2141401, employment questionnaire.
Boxes 1, 2 and 4 are to be filled out with the veterans name, file number, and social security number. You will find instructions on each part of va form 21526 to help you fill them out. If you dont send back the form you didnt receive, va sends you a notice of a proposal to reduce your tdiu benefit. The va form 214142 is known as an authorization and consent to release information to the department of veterans affairs va. Aug 26, 2011 va form 21 48 is a statement in support of claim. Approve forms using a lawful electronic signature and share them by way of email, fax or print them out. Va form 214142, authorization to disclose information to. Use these instructions to help you complete va form. Va form 214142, authorization to disclose information to the. Authorization to disclose information to the department of veterans affairsva fillable file type. Download fillable va form 214192 in pdf the latest version applicable for 2020.
For free help in completing this form, call va tollfree at 1800827. Department of veterans affairs form 21 4142 author. Va form 214142, authorization and consent to release information to the va. Veteranbeneficiarys name first, middle initial, last 2. Example of a completed va 2148 veterans benefits network. Enter your official contact and identification details. You can find answers to most questions and file a claim online at. I am getting ready to file another claim but am not using the vso i had in jan. A va form 214142 is known as an authorization and consent to release information. You can fill out va form 210781 when you file a disability claim online. Va form 214142 authorization for release of information. This week on e bennies was posted return forms 21 4141 and 21 4142 a by 5 may 16.
The advanced tools of the editor will direct you through the editable pdf template. Fdc criteria claims for veterans disability compensation and related compensation benefits 1. Form va 214142 authorization and consent to release. Form name instrument file url available electronically. Home va commonly used forms va compensation and pension forms va form 214142 authorization for release of information.
Note please read the entire form both pages before signing in item below. This is a critical form in continuing your va benefits, but will only be. Fill out the request for employment information in connection with claim for disability benefits online and print it out for free. The form must be completed in order for the va to obtain information regarding your medical treatments and history. Authorization to disclose information to the department of veterans affairs va fillable file type. Department of veterans affairs 810 vermont avenue, nw washington dc 20420. Attendance based on nursing home attendance, a va form 210779, request for nursing home information in connection with claim for aid and attendance. Ccss first name middle name last name of veteran type or print. Request for dd 214 or other military records nara sf 180. If you are unable to find your form here, you may want to visit.
Aug 17, 2012 to download the form va 21 4142 form in printable format and to know about the use of this form, who can use this form va 21 4142 form and when one should use this form va 21 4142 form. Va form 214192 download fillable pdf or fill online request. Frequently asked questions for what do i use va form 21526. You were seriously ill while you were in the service, and you believe you have continuing problems you developed a mental or physical condition that. To download the form va 21 4142 form in printable format and to know about the use of this form, who can use this form va 21 4142 form and when one should use this form va 21 4142 form. Not knowing what to make of it other then an authorization to release my medical records to the va. Va forms 214142 and 214142a veterans benefits network. Va form 214142, authorization and consent to release information to the. Va form 214142 authorization and consent to release information to the. Sf form 180 request pertaining to military records. At the end of the 21526, you will find a va form 214142. The va form 21 4140 should be mailed to you on the anniversary of your award. If you use a telecommunications device for the deaf tdd, the federal number is 711.
Ssn by itself will not result in the denial of benefits. Feb 26, 2017 i am slowly getting there i was wondering exactly what the va is after on the medical provider form 21 4142a. But all too often, you dont get the form in the mail. Title 38, united states code, allows us to ask for this information. M211mr part i manual for disability compensation veterans rights. I have read both pages of this form and agree to the disclosures above from the types of sources listed. Va form 5655 financial status report 1,387k va form 21 4142 authorization and consent to release information to the department of veterans affairs va 450k va form 21 0958 notice of disagreement 3,308k va form 21 0845 authorization to disclose personal information to a third party 617k va form 3288 request for consent to. You posted, i dont just want to put on there that i am request a rating increase because of xyz and my supporting documents are attached.
Va form 214142 veterans benefits administration veterans affairs. Submit your claim on a signed and completed va form 21526ez. The veterans benefits administration vba uses va form 21 4142, authorization to disclose information to the department of veterans affairs va, to request private medical records and information regarding the source of records in support of claims for compensation andor pension benefits. Veterans application for compensation and or pension 21 526, supplemental application for compensation 21 526b, authorization to disclose information to the department of veterans affairs 21 4142. Va 21 4142 authorization and consent to release information. General release for medical provider information to the department of veterans affairs va fillable file type. Va 214142 2014 2019 printable and fillable, blank pdf.
Video instructions and help with filling out and completing va form 21 4142. Fill out forms electronically working with pdf or word format. And what is the difference between these two forms. The va will not deny an individual benefits for refusing to provide his or her ssn unless the disclosure of the ssn is required by federal statute of law in effect prior to january 1, 1975, and still in effect. Federal law permits sources with information about you to release that information if you sign a single authorization to release all your information from all possible sources. You sign it to verify you arent employed and send it back. Should i apply for compensation or pension benefits. If you want to file a claim for va benefits, then you will find the forms to get started. In addition, the veteran will need to list the sources where the va can find pertinent information, as well as the dates that medical treatments occurred. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.