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GS*HS*52095*52095*251211*1612*1073904009*X*005010X279A1~
ST*270*000000226*005010X279A1~
BHT*0022*13*000000226*2512345*1612~
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*GIBBS*WILLIAM****MI*01127630~
DMG*D8*19500716*M~
DTP*291*RD8*20251211-20260311~
EQ*42~
EQ*30~
SE*14*000000226~
GE*1*226~
IEA*1*000000226~