ISA*00*          *00*          *ZZ*00000AAA       *ZZ*0000BBB        *040709*3339*U*00401*000484889*1*P*:~
GS*HC*0AAA *0BBB *20040709*1439*1*X*004010X096A1~
ST*837*300145997 ~
BHT*0019*00*300145997*20040709*1439*RP~
REF*87*004010X096A1~
NM1*41*2*PROVIDER 1*****46*0AAA~
PER*IC*HELPDESK*EM*ADMIN@NULL.NULL*TE*8005557444~
NM1*40*2*RECEIVER 1*****46*000111~
HL*1**20*1~
NM1*85*2*PROVIDER 1*****24*555112222~
N3*PROVIDER 1~
N4*THREE RIVERS*MI*49093~
REF*1D*1705555~
HL*2*1*22*0~
SBR*S*18*******11~
NM1*IL*1*ARNOLD*TOM****MI*666333444~
N3*5324 ELM~
N4*STURGIS*MI*49091~
DMG*D8*19270312*M~
REF*SY*666333444~
NM1*PR*2*PAYER 2*****PI*000111~
N3*PO BOX 0000~
N4*KALAMAZOO*MI*48001~
CLM*12522228*0***11:A:7*Y*A*Y*A*********N~
DTP*434*RD8*20031213-20031218~
DTP*435*DT*200312130800~
CL1*9*9*09~
REF*F8*12522228~
HI*BK:29689*BJ:29689~
NM1*71*1*EXTERNAL*PROVIDER*C***34*999999999~
PRV*AT*ZZ*101Y00000X~
REF*0B*9999999~
NM1*FA*2*PROVIDER 1~
PRV*RP*ZZ*101Y00000X~
N3*PROVIDER 1~
N4*THREE RIVERS*MI*49093~
SBR*T*18**PAYER A*****11~
AMT*B6*605.0000~
AMT*C4*0~
DMG*D8*19570312*M~
OI***Y***I~
NM1*IL*1*ARNOLD*TOM****MI*00000007018~
N3*5324 ELM~
N4*STURGIS*MI*49091~
NM1*PR*2*PAYER A*****PI*552312313~
DTP*573*D8*20040210~
REF*F8*1253278~
SBR*P*18**PROVIDER 1*****11~
AMT*B6*605.0000~
AMT*C4*0~
DMG*D8*19570312*M~
OI***Y***I~
NM1*IL*1*ARNOLD*TOM****MI*00000007018~
N3*5324 ELM~
N4*STURGIS*MI*49091~
NM1*PR*2*PROVIDER 1*****PI*13256235~
REF*F8*1253278~
LX*1~
SV2*0100**0*UN*5*0*0~
DTP*472*RD8*20031213-20031218~
SVD*5222312313*0**0100*5~
DTP*573*D8*20040210~
SVD*13256235*0**0100*5~
DTP*573*D8*20040210~
SE*63*300145997~
GE*1*1~
IEA*1*000484889~