PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title
38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection
of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification
of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation
and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number
(SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed may not be able to identify and locate your records, and provide a
copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your
SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. 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.
PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact
knowing it to be false.
RESPONDENT BURDEN: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for this information. We estimate that
you will need an average of 5 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you may
call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
11B. DATE(S) OF TREATMENT:
(Include the time period (MMDDYY)
for the treatment by the provider listed in Item 11A)
11C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
From:
To:
11A. PROVIDER OR FACILITY NAME
VETERAN'S SOCIAL SECURITY NO.
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
12B. DATE(S) OF TREATMENT:
(Include the time period (MMDDYY)
for the treatment by the provider listed in Item 12A)
12C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
From:
To:
12A. PROVIDER OR FACILITY NAME
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
13B. DATE(S) OF TREATMENT:
(Include the time period (month/day/year)
for the treatment by the provider listed in Item 13A)
13C. PROVIDER/FACILITY STREET ADDRESS (Number and street, P.O. or rural route)
From:
To:
13A. PROVIDER OR FACILITY NAME
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
VA FORM 21-4142a, MAR 2018
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