Supporting evidence for a disability compensation claim
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
VA Form 21-4142a — List private providers
Identify private providers and treatment dates for a records request, alongside the applicable authorization.
Use the current official form
Revision: August 2024.
Attach it to the applicable claim or review request; sending evidence alone does not necessarily initiate a review. Other benefit destinations are separate.
Submission instructions
In person
Disability compensation documents through the applicable claim or review channel.
A VA regional benefits office