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81,7(' 0(', &$/ &(17(56 NAME: DOB: ANNUAL ACCT #: SLIDING FEE SCALE PATIENT PAYS 20× 80% DISCOUNT PATIENT PAYS 0× 100% DISCOUNT B C D E F 1 0 11,880 11,881 14,850 14.851 17,820 17,821 20,790 20,791

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