Laws.com legal forms guide a VA Form 21-41 42 is a United States Department of Veterans Affairs form. - This form is used to authorize and provide consent for the release of medical information to the VA. - Before Veterans Affairs can review any medical or disability claims, this form must be on file. - The VA Form 21-41 42 can be found on the Veterans Affairs documentation website or obtained through a local Veterans Affairs office. - The first section of the form is for general identification information. - Sections 1, 2 & 4 must be filled out with the veteran's name, file number, and social security number. - If a claimant other than the veteran is seeking benefits, their name, relationship, and social security number must be provided in sections 3, 5, & 6. - Section 2 requires identifying all sources of medical information for which Veterans Affairs can have access. This includes providing the names and addresses of all relevant offices. - Dates, conditions, and illnesses for which the veteran received treatment must be included in this section as well. - Any additional comments about consent that may be helpful for Veterans Affairs can be provided. - Section 3 contains important privacy information that the Department of Veterans Affairs will adhere to. - The authorization must be checked in section 9. - The veteran, claimant, or legal representative must provide their signature as consent on the form. - Contact information, including address and phone numbers, should be included. - This is important as Veterans Affairs may need to contact the individual regarding the form and obtaining additional information for claims processing. - In section 11, it is necessary to have a witness sign and date the form. While this is not required for all medical records, Veterans Affairs may need a witness statement for some records. - Once completed, the VA Form 21-41...
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Va 21-4142 Form: What You Should Know
The form includes a Statement of Identity (S.I.), signature and date. It must be signed by the user, and must be signed on the face by a person authorized to sign on the user's behalf. The form is for the release of information from a Department of Veterans Affairs (VA) medical record or record of burial which is held by a custodian. The record must have a VA identification number and be located in a VA database, and may not be accessed any other place by the user of the form. VA Form 21-4142 is a VA-approved form to release information to VA. It is not a Federal Records Act (FRA) or public information act. VA Form 21-4142 does not require an individual to provide a reason for requesting the information. It does, however, state that the information to be released is not: (1) protected by privacy, confidentiality, or proprietary rights and (2) the release of which would constitute an unwarranted invasion of personal privacy. “Unwarranted invasion” means to release or disclose information with no legitimate purpose and no legitimate need. VA does not accept any responsibility, or liability, for the use or misuse of the information disclosed by a Veteran or an individual who receives an Authorization for Release of Information under this Form 21-4142. The VA will only authorize the release of Medical Record Information if the records or burial records are held by a VA employee. This Authorization is only for the release of information and information is only released when the individual who requested the information is authorized by the custodian to do so. The Veteran who is the custodian will not be authorized to make any changes to the information in the record. Vets with Service-Connected Injury or Illness (SCI) and VA Disability benefits received from a non-VA health care provider are eligible for the records released by VA under this authorization. Section III of this Form 21-4142 contains instructions for VA to send this form to a third party who is receiving information in response to an Application for Disability, Compensation, or Retirement (PERSIA) submitted to VA for review. Section IV contains instructions for VA to send the information obtained by the non-VA party to the third party. These instructions are in addition to the actual form, and must be used to complete the form and for processing by VA. VA Form 21-4142 — Authorization For Releases of Information To Creditors Effective date: Mar 2018.
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