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GS*HS*52095*52095*251103*0811*1487113239*X*005010X279A1~
ST*270*000034839*005010X279A1~
BHT*0022*13*000034839*2511307*0811~
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*LETTS*PATRICK****MI*261278954~
DMG*D8*19541217*M~
DTP*291*RD8*20251103-20260201~
EQ*42~
EQ*30~
SE*14*000034839~
GE*1*34839~
IEA*1*000034839~