P.O. Box 191 Princess Anne, MD 21853

410-651-1000

John Doe

Sliding Fee Authorization - Effective 4/1/07 – 3/31/08

Co-Pay: $20.00 Medical, $40.00 Dental

TLC Pharmacy: 340B Meds • Reduced Lab: Co-Pay D.O.S.

www.tlccs.org

For use at TLC Clinics ONLY