ISA*03*SENDER    *01*          *ZZ*SENDER         *ZZ*RECEIVER       *040608*1333*U*00401*000000288*0*P*:~
GS*HC*SENDER*RECEIVER*20040608*1333*56*X*004010X098A1~
ST*837*000000001~
BHT*0019*00*289*20040608*1333*CH~
REF*87*004010X098A1~
NM1*41*2*SENDER 1*****46*2309-0923~
PER*IC*Contact Name*TE*1115551111~
NM1*40*2*Payer*****46*21312311~
HL*1**20*1~
HL*2*1*22*0~
SBR*P*18*******11~
NM1*IL*1*GAIMAN*NEIL*M***MI*101911111~
N3*1123 OAKLAND~
N4*VOID*MI*49001~
DMG*D8*19460101*M~
REF*SY*370600001~
NM1*PR*2*PAYER 1*****PI*44-4444444~
N3*4444 ONE RD~
N4*VOID*MI*49001~
CLM*6643-1019AA*14.84***12::1*Y*A*N*Y*B~
HI*BK:29590~
LX*1~
SV1*HC:H2015*14.84*UN*6***1~
DTP*472*D8*20040501~
REF*6R*AKLKJ124231AD~
SE*24*000000001~
GE*1*56~
IEA*1*000000288~