VA Form 21-4142 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1. VETERAN'S NAME (First, Middle Initial, Last)FirstMiddleLast2. SOCIAL SECURITY NUMBER3. VA FILE NUMBER (If applicable)5. VETERAN'S SERVICE NUMBER (If applicable)6. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)No. & Stree Apt./Unit NumberCityState/ProvinceCountryZIP Code/Postal Code7. TELEPHONE NUMBER (Include Area Code)Enter International Phone Number (If applicable)8. E-MAIL ADDRESS (Optional)I agree to receive electronic correspondence from VA in regards to my claim.I agree9. PATIENT'S NAME (First, Middle Initial, Last)FirstMiddleLast10. SOCIAL SECURITY NUMBER11. VA FILE NUMBER (If applicable)VETERAN'S SOCIAL SECURITY NO.12. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):14. DATE SIGNED (MM/DD/YYYY) (Required)15. PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last)FirstMiddleLast16. RELATIONSHIP TO VETERAN/CLAIMANT (If other than self, please provide full name, title, organization, street, city, State, and ZIP code. All court appointments must include docket number, county, and State)1. VETERAN'S NAME (First, Middle Initial, Last) *FirstMiddleLast2. SOCIAL SECURITY NUMBER3. VA FILE NUMBER 5. VETERAN'S SERVICE NUMBER (If applicable)6. PATIENT'S NAME (First, Middle Initial, Last)FirstMiddleLast7. SOCIAL SECURITY NUMBER8. VA FILE NUMBER9A. PROVIDER OR FACILITY NAME 9B. CONDITIONS YOU ARE BEING TREATED FOR FROMTO9D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)No. & StreetApt./Unit NumberCityState/ProvinceCountry ZIP Code/Postal Code10A. PROVIDER OR FACILITY NAME 10B. CONDITIONS YOU ARE BEING TREATED FOR From:To:10D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)No. & StreetApt./Unit NumberCityState/ProvinceCountryZIP Code/Postal CodeVETERAN'S SOCIAL SECURITY NO11A. PROVIDER OR FACILITY NAME 11B. CONDITIONS YOU ARE BEING TREATED FOR From: To:11D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)No. & StreetApt./Unit NumberCityState/ProvinceCountryZIP Code/Postal Code12A. PROVIDER OR FACILITY NAME12B. CONDITIONS YOU ARE BEING TREATED FOR From:To:12D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)No. & Street Apt./Unit NumberCityState/ProvinceCountryZIP Code/Postal Code13A. PROVIDER OR FACILITY NAME13B. CONDITIONS YOU ARE BEING TREATED FORFrom:To:13D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)No. & StreetApt./Unit NumberCityState/ProvinceCountryZIP Code/Postal CodeSubmit
