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GS*HS*52095*52095*260410*0304*1073904009*X*005010X279A1~
ST*270*000001982*005010X279A1~
BHT*0022*13*000001982*2604100*0304~
HL*1**20*1~
NM1*PR*2*KAISER MEDICAID*****PI*52095~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*NEWBRAUGH*RODNEY****MI*28339740~
DMG*D8*19660403*M~
DTP*291*RD8*20260410-20260709~
EQ*42~
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GE*1*1982~
IEA*1*000001982~