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GS*HS*52095*52095*260203*1702*1487113239*X*005010X279A1~
ST*270*000004825*005010X279A1~
BHT*0022*13*000004825*260234*1702~
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*ROSS*NANCY****MI*62253246~
DMG*D8*19410709*F~
DTP*291*RD8*20260203-20260504~
EQ*42~
EQ*30~
SE*14*000004825~
GE*1*4825~
IEA*1*000004825~