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GS*HS*52095*52095*250814*1608*1487113239*X*005010X279A1~
ST*270*000004325*005010X279A1~
BHT*0022*13*000004325*2508226*1608~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE ADVANTAGE - PT SAFETY ASSESSMENT*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*LOGAN*BETTIE****MI*241287844~
DMG*D8*19570715*F~
DTP*291*RD8*20250814-20251112~
EQ*42~
EQ*30~
SE*14*000004325~
GE*1*4325~
IEA*1*000004325~