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GS*HS*52095*52095*260302*0803*1487113239*X*005010X279A1~
ST*270*000041665*005010X279A1~
BHT*0022*13*000041665*260361*0803~
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*WHITE*ALICE****MI*89333025~
DMG*D8*19580908*F~
DTP*291*RD8*20260302-20260531~
EQ*42~
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IEA*1*000041665~