VA Form 21-4142 ยท v2.2
Authorization to release medical records
Replaced by the combined records authorization. Kept here so old submissions still resolve against a schema.
3 fields in v2.2
Each field records where it came from on the paper form, so a reviewer can always trace a digital answer back to the box it replaced.
| Type | Required | On the paper form | Maps to | |
|---|---|---|---|---|
| veteran_full_nameVeteran's full name | Text | Yes | Page 1, box 1 | claimant.fullName |
| provider_nameProvider or facility name | Text | Yes | Page 2, box 11 | evidence.providerName |
| treatment_datesTreatment dates | Text | No | Page 2, box 12 | evidence.treatmentDates |
Field schema for VA Form 21-4142
- Field
- veteran_full_nameVeteran's full name
- Type
- Text
- Required
- Yes
- On the paper form
- Page 1, box 1
- Maps to
- claimant.fullName
- Field
- provider_nameProvider or facility name
- Type
- Text
- Required
- Yes
- On the paper form
- Page 2, box 11
- Maps to
- evidence.providerName
- Field
- treatment_datesTreatment dates
- Type
- Text
- Required
- No
- On the paper form
- Page 2, box 12
- Maps to
- evidence.treatmentDates
Validation rules
A rule can block a submission, warn the person filling it out, or flag the record for a person to review. No rule approves, denies, or prices anything.
| Field | Rule | When it fires | Effect |
|---|---|---|---|
| provider_name | Required before the release is sent | On submission | Blocks submission |
Validation rules for VA Form 21-4142
- Field
- provider_name
- Rule
- Required before the release is sent
- When it fires
- On submission
- Effect
- Blocks submission
Downstream mapping
Where each answer lands: VBMS - Evidence package.
Mapped (3)
- veteran_full_nameclaimant.fullName
- provider_nameevidence.providerName
- treatment_datesevidence.treatmentDates
Not mapped (0)
Nothing left to map on this form.
Test submissions
Synthetic payloads run against the current schema. A failed test means a rule caught something, which is usually the point.
Run a test submission
Sends a synthetic payload through validation and the downstream mapping. Nothing reaches a real system of record.
| Test case | Run on | Result | What happened |
|---|---|---|---|
| Final regression before retirement | January 15, 2026 | Passed | Archived. No new submissions accepted. |
Test submissions for VA Form 21-4142
- Test case
- Final regression before retirement
- Run on
- January 15, 2026
- Result
- Passed
- What happened
- Archived. No new submissions accepted.