ISA*00* *00* *ZZ*SENDERIDISA06*ZZ*RECEIVERIDISA08*120219*0910*|*00501*000000001*1*P*: GS*HC*SENDERCODE*RECEIVERCODE*20120219*0910*1*X*005010X222A1 ST*837*0001*005010X222A1 BHT*0019*00*11AAAA*20120219*0910*CH NM1*41*2*PRACTICE NAME*****46*SENDERID PER*IC*FIRST LAST*TE*8003334747 NM1*40*2*CCB MEDICAID*****46*RECEIVERID HL*1*1*20*1 NM1*85*2*HAPPY VALLEY MEDICAL CLINIC*****XX*1234567891 N3*5222 E. BASELINE RD. N4*GILBERT*AZ*85234 REF*EI*123456789 NM1*87*2 N3*1944 N. KLUGE DR.*SUITE 8381 N4*GILBERT*AZ*85234 HL*1*1*22*1 SBR*P*18*25BB******CH NM1*IL*1*YOUNGBLOOD*MICHAEL*C***MI*USAA236678 N3*73982 N. 28TH AVE. N4*PHOENIX*AZ*85044 DMG*D8*19620705*M NM1*PR*2*U.S. TRICARE*****PI CLM*17*5007.5***11:B:1*Y*A*Y*Y**OA:EM DTP*439*D8*20100101 HI*BK:8472*BF:73730*BF:3469 NM1*82*1*HINCKLE*WALLACE****XX*9876543210 PRV*PE*PXC*PROVITAXON LX*1 SV1*HC:99000:::::HANDLING FEE*8*UN*1***1:2:3 DTP*472*D8*20120219 REF*6R*100 LX*1 SV1*HC:J0490:::::BENADRYL HCL, UP TO 50 MG.*4999.5*UN*1***1:2:3 DTP*472*D8*20120219 REF*6R*99 LIN**N4*12345678901 CTP****50*UN SE*9999*0001 GE*9999*1 IEA*9999*000000001