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GS*HS*52095*52095*251215*0812*1487113239*X*005010X279A1~
ST*270*000037489*005010X279A1~
BHT*0022*13*000037489*2512349*0812~
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*SMITH*WALTER****MI*75216648~
DMG*D8*19600304*M~
DTP*291*RD8*20251215-20260315~
EQ*42~
EQ*30~
SE*14*000037489~
GE*1*37489~
IEA*1*000037489~