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This authorization includes information placed in my record after the date of my signature and before the expiration of my consent. Signature of ALF Resident.Please present the completed and signed form at the time of the removal. Pursuant to Va. Code § 8. 01-453, the undersigned directs that the clerk of the court referenced in item number 3 shall enter the. Get VA Form 105345, Request for and Authorization to Release Health Information. City of Norfolk • 810 Union Street • Suite 100 • Norfolk, VA 23510 • 757-664-4486. NOTE: Complete this form if you are requesting DMV to release your driving record to anyone other than yourself. Blacksburg, VA 24061. PER INCIDENT (This is not a blanket release).