ISA*00*          *00*          *ZZ*00HP           *ZZ*ENCOUNTER      *040820*1133*U*00401*000484950*1*P*:~
GS*HC*00HP*ENCOUNTER*20040820*1133*1*X*004010X096A1~
ST*837*300207436~
BHT*0019*00*300207436*20040820*1133*RP~
REF*87*004010X096A1~
NM1*41*2*SENDER 1*****46*00HP~
PER*IC*CONTACT 1*TE*8005557487~
NM1*40*2*RECEIVER 1*****46*D00111~
HL*1**20*1~
NM1*85*2*BILLING PROVIDER 1*****24*445556666~
N3*456 MAIN STREET~
N4*THREE RIVERS*MI*49093~
REF*1D*1708146~
HL*2*1*22*0~
SBR*S*18*******MC~
NM1*IL*1*MANN*MICHAEL****MI*11331122~
N3*123 ELM STRET~
N4*BURR OAK*MI*49030~
DMG*D8*19950801*M~
REF*SY*363121212~
NM1*PR*2*MDCH*****PI*D00111~
N3*PO BOX 4321~
N4*LANSING*MI*48909~
CLM*1309590*0***11:A:1*Y*A*Y*A*********N~
DTP*434*RD8*20040618-20040623~
DTP*435*DT*200406180800~
CL1*9*9*09~
CN1*05~
HI*BK:31389*BJ:31389~
NM1*71*1*EXTERNAL*PROVIDER*C***34*999999999~
PRV*AT*ZZ*101Y00000X~
REF*0B*9999999~
NM1*FA*2*ST JOSEPH COUNTY CMH~
PRV*RP*ZZ*101Y00000X~
N3*456 MAIN STREET~
N4*THREE RIVERS*MI*49093~
SBR*P*18**KALAMAZOO CMH*****MC~
AMT*B6*632.5000~
DMG*D8*19950801*M~
OI***Y***I~
NM1*IL*1*MANN*MICHAEL****MI*00000006632~
N3*123 ELM STRET~
N4*BURR OAK*MI*49030~
NM1*PR*2*KALAMAZOO CMH*****PI*174456543~
DTP*573*D8*20040816~
REF*F8*1309590~
SBR*T*18**SENDER 1 HEALTH*****MC~
AMT*B6*632.5000~
DMG*D8*19950801*M~
OI***Y***I~
NM1*IL*1*MANN*MICHAEL****MI*00000006632~
N3*123 ELM STRET~
N4*BURR OAK*MI*49030~
NM1*PR*2*SENDER 1*****PI*174454370~
REF*F8*1309590~
LX*1~
SV2*0100**0*UN*5*0*0~
DTP*472*RD8*20040618-20040623~
SVD*174456543*0**0100*5~
DTP*573*D8*20040816~
SE*60*300207436~
ST*837*300207437~
BHT*0019*00*300207437*20040820*1133*RP~
REF*87*004010X096A1~
NM1*41*2*SENDER 1*****46*00HP~
PER*IC*CONTACT 1*TE*8005557487~
NM1*40*2*RECEIVER 1*****46*D00111~
HL*1**20*1~
NM1*85*2*BILLING PROVIDER 1*****24*445556666~
N3*456 MAIN STREET~
N4*THREE RIVERS*MI*49093~
REF*1D*1708146~
HL*2*1*22*0~
SBR*S*18*******MC~
NM1*IL*1*WAHL*JAMES****MI*12341234~
N3*MT PLEASANT CENTER*1400 W MAIN~
N4*MT. PLEASANT*MI*48858~
DMG*D8*19750704*M~
REF*SY*374121234~
NM1*PR*2*MDCH*****PI*D00111~
N3*PO BOX 4321~
N4*LANSING*MI*48909~
CLM*1304171*0***11:A:1*Y*A*Y*A*********N~
DTP*434*RD8*20040601-20040701~
DTP*435*DT*200406010800~
CL1*9*9*09~
CN1*05~
HI*BK:31234*BJ:31234~
NM1*71*1*EXTERNAL*PROVIDER*C***34*999999999~
PRV*AT*ZZ*101Y00000X~
REF*0B*9999999~
NM1*FA*2*ST JOSEPH COUNTY CMH~
PRV*RP*ZZ*101Y00000X~
N3*456 MAIN STREET~
N4*THREE RIVERS*MI*49093~
SBR*P*18**KALAMAZOO CMH*****MC~
AMT*B6*216.7000~
DMG*D8*19750704*M~
OI***Y***I~
NM1*IL*1*WAHL*JAMES****MI*00000000043~
N3*MT PLEASANT CENTER*1400 W MAIN~
N4*MT. PLEASANT*MI*48858~
NM1*PR*2*KALAMAZOO CMH*****PI*174456543~
DTP*573*D8*20040719~
REF*F8*1304171~
SBR*T*18**SENDER 1 HEALTH*****MC~
AMT*B6*216.7000~
DMG*D8*19750704*M~
OI***Y***I~
NM1*IL*1*WAHL*JAMES****MI*00000000043~
N3*MT PLEASANT CENTER*1400 W MAIN~
N4*MT. PLEASANT*MI*48858~
NM1*PR*2*SENDER 1*****PI*174454370~
REF*F8*1304171~
LX*1~
SV2*0100**0*UN*30*0*0~
DTP*472*RD8*20040601-20040701~
SVD*174456543*0**0100*30~
DTP*573*D8*20040719~
SE*59*300207437~
GE*2*333~
IEA*5*333~