Use VA Form 105345 to authorize us to share your health information with a nonVA (or thirdparty) individual or organization. This form must be reviewed with the patient at least annually: This form must be filed in the medical record.This Texas HIPAA release form provides patients with access to their personal health records. The HIPAA form also allow healthcare providers to share records. Download Virginia Medical Records Release Form template, modify and send for signing using BoloForms Signature. Direct free access to PDF of HIPAA release. Free immediate download of medical relasese form PDF. This form will ensure that healthcare providers comply with the HIPAA mandates and local state laws to protect a person's health information. Fill out, sign, and date VA Form 1010164 (Opt Out of Sharing Protected Health Information). Mail the signed, completed form to our ROI office.