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GS*HS*52095*52095*251016*1610*1073904009*X*005010X279A1~
ST*270*000000757*005010X279A1~
BHT*0022*13*000000757*2510289*1610~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*HARNOIS*JOHN****MI*511057682~
DMG*D8*19451023*M~
DTP*291*RD8*20251016-20260114~
EQ*42~
EQ*30~
SE*14*000000757~
GE*1*757~
IEA*1*000000757~