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Authorization to Disclose Protected Health Information The Dickey Health and Wellness Center 401 W. Kennedy Blvd. If I fail to specify an expiration date event or condition this authorization will expire in 12 months. There is no charge for copying immunization records a single lab or diagnostic report or a single date of service only. Box 116F Tampa FL 33606 813 253-6250 Telephone 813 258-7413 Fax PLEASE NOTE This form must be signed in person at the health center. C. Please restrict the...
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