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AUTHORIZATION FOR RELEASE OF INFORMATION 1300 Miccosukee Road, Tallahassee, FL 32308PATIENT INFORMATION Date(s) of Service Requested:NAME: DATE OF BIRTH: / / LAST 4 NUMBERS OF SSN: DAY PHONE: / /
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1300 Miccosukee Road Tallahassee is a physical address in Tallahassee, Florida.
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