ISA*00**01*SECRET *ZZ*SUBMITTERS.ID *ZZ*RECEIVERS.ID *930602*1253*^*00401*000000905*1*T*:~
GS*HC*SENDER CODE*RECEIVER CODE*1994033*0802*1*X*004010X098A1~
ST*837*0021~
BHT*0019*00*0123*19981015*1023*RP~
REF*87*004010X098~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222*EX*231~
NM1*40*2*REPRICER XYZ*****46*66783JJT~
HL*1**20*1~
NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~
N3*234 Seaway St~
N4*Miami*FL*33111~
NM1*87*2*KILDARE ASSOC*****24*581234567~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*0~
SBR*P*18*12312-A******HM~
NM1*IL*1*SMITH*TED****34*000221111~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*M~
NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~
CLM*26462967*100***11::1*Y*A*Y*Y*C~
DTP*431*D8*19981003~
REF*D9*17312345600006351~
HI*BK:0340*BF:V7389~
NM1*82*1*KILDARE*BEN****34*112233334~
PRV*PE*ZZ*203BF0100Y~
NM1*77*2*KILDARE ASSOCIATES*****24*581234567~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
LX*1~
SV1*HC:99213*40*UN*1***1**N~
DTP*472*D8*19981003~
LX*2~
SV1*HC:87072*15*UN*1***1**N~
DTP*472*D8*19981003~
LX*3~
SV1*HC:99214*35*UN*1***2**N~
DTP*472*D8*19981010~
LX*4~
SV1*HC:86663*10*UN*1***2**N~
DTP*472*D8*19981010~
SE*42*0021~
GE*1*1~
IEA*1*000000905~

Last edited Apr 10, 2011 at 5:20 AM by dstrubhar, version 3

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