ISA*00*          *00*          *ZZ*00             *ZZ*               *060801*1308*U*00401*123456789*0*P*>~
GS*HC*22*33*060801*1308*6*X*004010X096A1~
ST*837*2222*~
BHT*0019*00*000002*060801*1308*CH~
REF*87*004010X096A1~
NM1*41*2*Marisa Tester*****46*00*~PER*IC*Marisa Tester*8887106888~
NM1*40*2*MEDICARE*****46*C00380~
HL*1**20*1~
NM1*85*2*ACME Home Health*****34*010419008~
N3*202 US Route 1~N4*Falmouth*ME*04105~
REF*1C*262331~PER*IC*Marisa Tester*TE*8887106888~
HL*2*1*22*0~SBR*P*18**UNKNOWN*****MA~
NM1*IL*1*Black*Barney****MI*112112112A~
N3*2 Albert Way~
N4*MACHIAS*AZ*22031*~DMG*D8*19360205*M~
NM1*PR*2*MEDICARE*****PI*C00380~
N3*MED*MED~
N4*MED*MED*99999~
CLM*Black Barney:08/27/2005*000***32>A>9*Y**Y*Y*********Y~
DTP*434*RD8*20050627-20050827~
DTP*435*DT*20050627~
CL1**1*x~
REF*G1*062720050627200501~
HI*BK>9641~
HI*BE>61>>>13498~ 
NM1*71*1*Castellanos*Jose****24*112112112~
REF*1G*B12345~
LX*1~
SV2*0023*HC>HAEL1*0*UN*4~
DTP*472*D8*20050627~
LX*1~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060123~
LX*2~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060130~
LX*3~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060206~
LX*4~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060213~
LX*5~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060220~
LX*6~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060227~
LX*7~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060306~
LX*8~
SV2*571*HC>122*20*UN*4~
DTP*472*D8*20060313~
SE*40*000000001~
GE*85*6~
IEA*1*123456789~