ISA>00>ISA02 >00>ISA04 >30>123456789 >ZZ>CLAIMSCH >080425>2002>U>00401>987654321>1>P>^~ GS>HC>908688055>05039844>20080>2002>11111111>X>004010X096A1~ ST>837>0001~ BHT>0019>00>124435>20080425>2002>CH~ REF>87>004010X096A1~ NM1>41>2>GENERAL BETHESDA HOSPITAL>>>>>46>200000200000~ PER>IC>GENERAL BETHESDA HOSPITAL>TE>8479419218>FX>0000000000~ NM1>40>2>TRANSACTION SOLUTION HUB>>>>>46>99999~ HL>1>>20>1~ PRV>BI>ZZ>111A00000X~ NM1>85>2>GENERAL BETHESDA HOSPI>>>>>XX>2222222222~ N3>123 MAIN ST~ N4>CHICAGO>IL>60042~ REF>1A>1111HBE~ REF>EI>234567890~ PER>IC>GENERAL BETHESDA HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL BETHESDA HOSPI>>>>>XX>2222222222~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>234567890~ HL>2>1>22>0~ SBR>P>18>EP111PC>>>>>>BL~ NM1>IL>1>SMITH>JANE>L>>>MI>GGPXZ1111111~ N3>894 N SPRUCE ST>APT 10~ N4>CHICAGO>IL>60046~ DMG>D8>19540106>F~ NM1>PR>2>BLUE CROSS MN G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>SMITH>JANE>L~ N3>894 N SPRUCE ST>APT 10~ N4>CHICAGO>IL>60046~ CLM>00512345>455>>>13^A^3>N>A>Y>Y>>>>>>>>>N~ DTP>434>RD8>20080424-20080424~ DTP>435>DT>200804241200~ CL1>3>1>30~ REF>EA>024000000~ HI>BK^V573~ HI>BF^79902~ HI>BH^35^D8^20080417>BH^45^D8^20080417~ HI>BE^50^^^2>BE^52^^^2~ NM1>71>1>JAMES>KENNETH>R>>>XX>1881664444~ REF>1G>D97531~ LX>1~ SV2>0420>HC^97112>102.5>UN>1~ DTP>472>D8>20080424~ LX>2~ SV2>0420>HC^97116>82>UN>1~ DTP>472>D8>20080424~ LX>3~ SV2>0440>HC^92507>270.5>UN>1~ DTP>472>D8>20080424~ HL>3>>20>1~ PRV>BI>ZZ>111A00000X~ NM1>85>2>GENERAL BETHESDA HOSPI>>>>>XX>2222222222~ N3>123 MAIN ST~ N4>CHICAGO>IL>60042~ REF>1A>1111HBE~ REF>EI>234567890~ PER>IC>GENERAL BETHESDA HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL BETHESDA HOSPI>>>>>XX>2222222222~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>234567890~ HL>4>3>22>0~ SBR>P>18>5WM00000001>>>>>>BL~ NM1>IL>1>MCNABB>JON>W>>>MI>WEFXZ1111111~ N3>PO BOX 784~ N4>SHAUMBURG>IL>60045~ DMG>D8>19501110>M~ NM1>PR>2>BC OF MN COMP CARE 220 G>>>>>PI>1513~ N3>P O BOX 64668~ N4>CHICAGO>IL>60063~ NM1>QD>1>MCNABB>JON>W~ N3>PO BOX 784~ N4>SHAUMBURG>IL>60045~ CLM>00512346>16866.1>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1100~ DTP>434>RD8>20080416-20080421~ DTP>435>DT>200804161600~ CL1>3>4>02~ REF>EA>025111111~ HI>BK^V550>BJ^51881~ HI>DR^205~ HI>BF^51881>BF^2639>BF^V551>BF^45341>BF^431>BF^34830>BF^43889>BF^V5873>BF^4019>BF^2989>BF^2724>BF^79029~ HI>BF^2449>BF^37775>BF^4387>BF^27801>BF^78050>BF^3079>BF^7038~ HI>BR^8627^D8^20080417~ HI>BQ^8965^D8^20080421~ HI>BE^01^^^1587~ HI>BG^38~ QTY>CA>5>DA~ NM1>71>1>AIKMAN>APRIL>D>>>XX>1679533333~ REF>1G>H32323~ NM1>72>1>BRADSHAW>RICHARD>G>>>XX>1811000000~ REF>1G>T93939~ LX>1~ SV2>0110>>8075>DA>5>1615~ LX>2~ SV2>0250>>1432.7>UN>129~ LX>3~ SV2>0271>>1641>UN>8~ LX>4~ SV2>0272>>290.5>UN>2~ LX>5~ SV2>0300>>272.5>UN>3~ LX>6~ SV2>0301>>880>UN>5~ LX>7~ SV2>0305>>374>UN>2~ LX>8~ SV2>0306>>446>UN>3~ LX>9~ SV2>0320>>152.4>UN>1~ LX>10~ SV2>0360>>96.5>UN>1~ LX>11~ SV2>0420>>366>UN>4~ LX>12~ SV2>0424>>186>UN>1~ LX>13~ SV2>0430>>224.5>UN>3~ LX>14~ SV2>0434>>186>UN>1~ LX>15~ SV2>0440>>195>UN>2~ LX>16~ SV2>0444>>262>UN>2~ LX>17~ SV2>0460>>1595.5>UN>6~ LX>18~ SV2>0730>>190.5>UN>1~ HL>5>>20>1~ PRV>BI>ZZ>111A00000X~ NM1>85>2>GENERAL BETHESDA HOSPI>>>>>XX>2222222222~ N3>123 MAIN ST~ N4>CHICAGO>IL>60042~ REF>1A>1111HBE~ REF>EI>234567890~ PER>IC>GENERAL BETHESDA HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL BETHESDA HOSPI>>>>>XX>2222222222~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>234567890~ HL>6>5>22>0~ SBR>P>18>P11111>>>>>>BL~ NM1>IL>1>JONES>JON>L>>>MI>NEI111111111~ N3>8374 OAK ST~ N4>CHICAGO>IL>60050~ DMG>D8>19580906>M~ NM1>PR>2>BLUE CROSS MN G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>JONES>JON>L~ N3>8374 OAK ST~ N4>CHICAGO>IL>60050~ CLM>00512347>102208.23>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1400~ DTP>434>RD8>20080131-20080227~ DTP>435>DT>200801311700~ CL1>3>4>01~ REF>G1>NEI76368~ REF>EA>018000000~ HI>BK^4210>BJ^4210~ HI>DR^288~ HI>BF^5845>BF^71101>BF^34290>BF^29620>BF^496>BF^32723>BF^4019>BF^2859>BF^25000>BF^27801>BF^70715>BF^7030~ HI>BF^53081>BF^2768>BF^2724>BF^30000>BF^2949>BF^04111>BF^V433~ HI>BR^9904^D8^20080211~ HI>BQ^8627^D8^20080204~ HI>BE^01^^^1587~ HI>BG^38~ QTY>CA>27>DA~ NM1>71>1>NAMATH>ALEXANDER>>>>XX>1669444444~ REF>1G>H49494~ NM1>72>1>NAMATH>ALEXANDER>>>>XX>1669444444~ REF>1G>H49494~ LX>1~ SV2>0110>>43605>DA>27>1615~ LX>2~ SV2>0250>>20489.73>UN>18757~ LX>3~ SV2>0258>>314>UN>4~ LX>4~ SV2>0271>>144>UN>2~ LX>5~ SV2>0300>>26>UN>1~ LX>6~ SV2>0301>>2124>UN>11~ LX>7~ SV2>0302>>1035.5>UN>9~ LX>8~ SV2>0305>>2055>UN>27~ LX>9~ SV2>0306>>175>UN>1~ LX>10~ SV2>0307>>88>UN>1~ LX>11~ SV2>0390>>560>UN>2~ LX>12~ SV2>0410>>11213>UN>81~ LX>13~ SV2>0420>>6212>UN>72~ LX>14~ SV2>0424>>186>UN>1~ LX>15~ SV2>0430>>4530>UN>56~ LX>16~ SV2>0434>>186>UN>1~ LX>17~ SV2>0440>>2730>UN>28~ LX>18~ SV2>0444>>262>UN>2~ LX>19~ SV2>0460>>5640>UN>48~ LX>20~ SV2>0921>>633>UN>1~ SE>214>0001~ ST>837>0002~ BHT>0019>00>124436>20080425>2002>CH~ REF>87>004010X096A1~ NM1>41>2>GENERAL HOSPICE PROGRAM>>>>>46>200001200001~ PER>IC>GENERAL HOSPICE PROGRAM>TE>8479419218>FX>0000000000~ NM1>40>2>TRANSACTION SOLUTION HUB>>>>>46>99999~ HL>1>>20>1~ PRV>BI>ZZ>222A00000X~ NM1>85>2>GENERAL HOSPICE>>>>>XX>1114944444~ N3>31 N 5TH ST~ N4>CHICAGO>IL>60053~ REF>1C>242424~ REF>1D>714555555~ REF>EI>123456789~ PER>IC>GENERAL HOSPICE PROGRAM>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL HOSPICE>>>>>XX>1114944444~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>123456789~ HL>2>1>22>0~ SBR>P>18>>>>>>>MA~ NM1>IL>1>THOMPSON>JANE>E>>>MI>411111111D~ N3>6334 15TH AVE S>RM 315B~ N4>S CHICAGO>IL>60051~ DMG>D8>19160209>F~ NM1>PR>2>MEDICARE B J>>>>>PI>5512~ NM1>QD>1>THOMPSON>JANE>E~ N3>6334 15TH AVE S>RM 315B~ N4>S CHICAGO>IL>60051~ CLM>00081234>3164.07>>>82^A^4>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1200~ DTP>434>RD8>20080301-20080321~ DTP>435>DT>200606011200~ CL1>3>1>01~ REF>EA>022000000~ NTE>ADD>PATIENT NON RECERT EFFT 03 21 08 CONDITION STABLE~ HI>BK^496~ HI>BF^V667~ HI>BH^18^D8^19810201>BH^27^D8^20080122>BH^42^D8^20080321~ HI>BE^61^^^33460~ HI>BG^09~ NM1>71>1>ELWAY>JESSICA>E>>>XX>1568422222~ REF>1G>F91919~ SBR>S>18>>>>>>>MC~ DMG>D8>19160209>F~ OI>>>Y>>>Y~ NM1>IL>1>THOMPSON>JANE>E>>>MI>01111111~ N3>6334 15TH AVE S~ N4>S CHICAGO>IL>60051~ NM1>PR>2>MINNESOTA M A D>>>>>PI>999999999~ N3>P O BOX 64165~ N4>CHICAGO>IL>60063~ LX>1~ SV2>0651>HC^Q5004>3164.07>UN>21~ DTP>472>D8>20080321~ SE>56>0002~ ST>837>0003~ BHT>0019>00>124437>20080425>2002>CH~ REF>87>004010X096A1~ NM1>41>2>GENERAL ST JOHNS HOSPITAL>>>>>46>200002200002~ PER>IC>GENERAL ST JOHNS HOSPITAL>TE>8479419218>FX>0000000000~ NM1>40>2>TRANSACTION SOLUTION HUB>>>>>46>99999~ HL>1>>20>1~ PRV>BI>ZZ>333A00000X~ NM1>85>2>GENERAL ST JOHNS HOSP>>>>>XX>3333333333~ N3>123 1ST ST~ N4>HAWTHORN WOODS>IL>60052~ REF>1A>1111HJO~ REF>EI>411455555~ PER>IC>GENERAL ST JOHNS HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL ST JOHNS HOSP>>>>>XX>3333333333~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>411455555~ HL>2>1>22>0~ SBR>P>18>5BL00000>>>>>>BL~ NM1>IL>1>BELL>JANE>A>>>MI>BHHXZ1111111~ N3>7594 PINE ST NE~ N4>LONG GROVE>IL>60044~ DMG>D8>19620524>F~ NM1>PR>2>BC OF MN COMP CARE 220 G>>>>>PI>1513~ N3>P O BOX 64668~ N4>CHICAGO>IL>600630668~ NM1>QD>1>BELL>JANE>A~ N3>7594 PINE ST NE~ N4>LONG GROVE>IL>60044~ CLM>05123456>19605.36>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1400~ DTP>434>RD8>20080213-20080214~ DTP>435>DT>200802130500~ CL1>3>1>01~ REF>EA>025112222~ HI>BK^62130>BJ^62130~ HI>DR^743~ HI>BF^2189>BF^6202>BF^53081>BF^2800>BF^3004>BF^V1251~ HI>BR^6859^D8^20080213~ HI>BQ^6529^D8^20080213~ HI>BE^02^^^0~ HI>BG^38~ QTY>CA>1>DA~ NM1>71>1>SANDERS>INGRID>>>>XX>1043233333~ REF>1G>D99777~ NM1>72>1>SANDERS>INGRID>>>>XX>1043233333~ REF>1G>D99777~ LX>1~ SV2>0110>>1615>DA>1>1615~ LX>2~ SV2>0250>>1049.46>UN>43~ LX>3~ SV2>0258>>314>UN>4~ LX>4~ SV2>0271>>591.5>UN>3~ LX>5~ SV2>0300>>78>UN>3~ LX>6~ SV2>0301>>90>UN>1~ LX>7~ SV2>0305>>90>UN>2~ LX>8~ SV2>0307>>182>UN>1~ LX>9~ SV2>0312>>578.4>UN>2~ LX>10~ SV2>0360>>8921>UN>1~ LX>11~ SV2>0370>>3700>UN>1~ LX>12~ SV2>0710>>2396>UN>5~ HL>3>>20>1~ PRV>BI>ZZ>333A00000X~ NM1>85>2>GENERAL ST JOHNS HOSP>>>>>XX>3333333333~ N3>123 1ST ST~ N4>HAWTHORN WOODS>IL>60052~ REF>1A>1111HJO~ REF>EI>411455555~ PER>IC>GENERAL ST JOHNS HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL ST JOHNS HOSP>>>>>XX>3333333333~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>411455555~ HL>4>3>22>1~ SBR>P>>EPO0000>>>>>>BL~ NM1>IL>1>BRADY>JAKE>E>>>MI>ADTXZ1111111~ N3>367 RIVER RD NE~ N4>VERNON HILLS>IL>60062~ DMG>D8>19781203>M~ NM1>PR>2>BLUE CROSS MN G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>BRADY>JESSICA>M~ N3>9478 MAPLE ST S~ N4>VERNON HILLS>IL>60062~ HL>5>4>23>0~ PAT>19~ NM1>QC>1>BRADY>JON~ N3>367 RIVER RD NE~ N4>VERNON HILLS>IL>60062~ DMG>D8>20080219>M~ CLM>05123457>2288.99>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1200~ DTP>434>RD8>20080219-20080221~ DTP>435>DT>200802192000~ CL1>4>5>01~ REF>EA>025333333~ HI>BK^V3001>BJ^V3001~ HI>DR^795~ HI>BE^02^^^0>BE^54^^^4340~ HI>BG^09>BG^38~ QTY>CA>2>DA~ NM1>71>1>ROBERTS>WILLIAM>O>>>XX>1154400000~ REF>1G>A95959~ LX>1~ SV2>0171>>1730>DA>2>865~ LX>2~ SV2>0250>>150.89>UN>3~ LX>3~ SV2>0301>>209.1>UN>8~ LX>4~ SV2>0302>>199>UN>3~ SE>124>0003~ ST>837>0004~ BHT>0019>00>124438>20080425>2002>CH~ REF>87>004010X096A1~ NM1>41>2>GENERAL ST JOSEPHS HOSPITAL>>>>>46>200003200003~ PER>IC>GENERAL ST JOSEPHS HOSPITAL>TE>8479419218>FX>0000000000~ NM1>40>2>TRANSACTION SOLUTION HUB>>>>>46>99999~ HL>1>>20>1~ PRV>BI>ZZ>333A00000X~ NM1>85>2>GENERAL ST JOSEPHS HOS>>>>>XX>4444444444~ N3>31 N 5TH ST~ N4>CHICAGO>IL>60053~ REF>1A>1111HJO~ REF>EI>123456789~ PER>IC>GENERAL ST JOSEPHS HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL ST JOSEPHS HOS>>>>>XX>4444444444~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>123456789~ HL>2>1>22>0~ SBR>P>18>EP111WO>>>>>>BL~ NM1>IL>1>MONTANA>JON>M>>>MI>XQI111AD2222~ N3>376 CEDAR AVE~ N4>CHICAGO>IL>60060~ DMG>D8>19840721>M~ NM1>PR>2>BLUE CROSS MN G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>MONTANA>JON>M~ N3>376 CEDAR AVE~ N4>CHICAGO>IL>60060~ CLM>0412345>14346.79>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1300~ DTP>434>RD8>20080205-20080212~ DTP>435>DT>200802050100~ CL1>1>7>01~ REF>EA>025334444~ HI>BK^30301>BJ^30301~ HI>DR^895~ HI>BF^30000~ HI>BR^9463^D8^20080205~ HI>BH^11^D8^20080205~ HI>BE^01^^^1587~ HI>BG^09~ QTY>CA>7>DA~ NM1>71>1>YOUNG>DAVID>A>>>XX>1598722222~ REF>1G>H73737~ NM1>72>1>YOUNG>DAVID>A>>>XX>1598722222~ REF>1G>H73737~ LX>1~ SV2>0120>>11109>DA>7>1587~ LX>2~ SV2>0250>>428.03>UN>32~ LX>3~ SV2>0253>>175.5>UN>2>>175.5~ LX>4~ SV2>0258>>81.36>UN>1~ LX>5~ SV2>0300>>37.4>UN>1~ LX>6~ SV2>0301>>1062>UN>13~ LX>7~ SV2>0305>>140>UN>1~ LX>8~ SV2>0450>>1313.5>UN>1~ HL>3>>20>1~ PRV>BI>ZZ>333A00000X~ NM1>85>2>GENERAL ST JOSEPHS HOS>>>>>XX>4444444444~ N3>31 N 5TH ST~ N4>CHICAGO>IL>60053~ REF>1A>2222HJO~ REF>EI>123456789~ PER>IC>GENERAL ST JOSEPHS HOSPITAL>TE>8479419218>FX>0000000000~ NM1>87>2>GENERAL ST JOSEPHS HOS>>>>>XX>4444444444~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>123456789~ HL>4>3>22>1~ SBR>P>>4S111AO>>>>>>BL~ NM1>IL>1>KING>JANET>>>>MI>XZAXZ1111111~ N3>4683 BIRCH RD~ N4>LONG GROVE>IL>60043~ DMG>D8>19800206>M~ NM1>PR>2>BLUE CROSS MN G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>KING>AMANDA>T~ N3>584 WILLOW CT~ N4>LONG GROVE>IL>60043~ HL>5>4>23>0~ PAT>19~ NM1>QC>1>KING>JON>G~ N3>4683 BIRCH RD~ N4>LONG GROVE>IL>60043~ DMG>D8>20080310>M~ CLM>0412346>2271.66>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1200~ DTP>434>RD8>20080310-20080312~ DTP>435>DT>200803100800~ CL1>4>5>01~ REF>EA>025555555~ HI>BK^V3000>BJ^V3000~ HI>DR^795~ HI>BF^7746>BF^7788>BF^V053~ HI>BE^01^^^1587~ HI>BG^09~ QTY>CA>2>DA~ NM1>71>1>UNITAS>JENNIFER>>>>XX>1932188888~ REF>1G>E58585~ LX>1~ SV2>0171>>1730>DA>2>865~ LX>2~ SV2>0250>>152.56>UN>3~ LX>3~ SV2>0301>>389.1>UN>10~ SE>115>0004~ ST>837>0005~ BHT>0019>00>124439>20080425>2002>CH~ REF>87>004010X096A1~ NM1>41>2>JASONS HEALTH CAMPUS>>>>>46>200004200004~ PER>IC>JASONS HEALTH CAMPUS>TE>8479419218>FX>0000000000~ NM1>40>2>TRANSACTION SOLUTION HUB>>>>>46>99999~ HL>1>>20>1~ PRV>BI>ZZ>333A00000X~ NM1>85>2>JASONS HEALTH CAMPUS>>>>>XX>5555555555~ N3>794 2ND ST~ N4>ROUND LAKE>IL>60054~ REF>1A>1F11HHE~ REF>EI>411599999~ PER>IC>JASONS HEALTH CAMPUS>TE>8479419218>FX>0000000000~ NM1>87>2>JASONS HEALTH CAMPUS>>>>>XX>5555555555~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>411599999~ HL>2>1>22>1~ SBR>P>>EP22222>>>>>>BL~ NM1>IL>1>SPENCER>JON>E>>>MI>CNXXZ1111111~ N3>174982 CHESNUT ST~ N4>ROUND LAKE>IL>60061~ DMG>D8>20080316>M~ NM1>PR>2>BLUE CROSS MN G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>SPENCER>CHERYL>M~ N3>174982 CHESNUT ST TR~ N4>ROUND LAKE>IL>60061~ HL>3>2>23>0~ PAT>19~ NM1>QC>1>SPENCER>ADDISON>M~ N3>174982 CHESNUT ST~ N4>ROUND LAKE>IL>60061~ DMG>D8>20080316>F~ CLM>01234567>2049.74>>>11^A^1>N>A>Y>Y>>>>>>>>>N~ DTP>096>TM>1100~ DTP>434>RD8>20080316-20080318~ DTP>435>DT>200803161500~ CL1>4>5>01~ REF>EA>025666666~ HI>BK^V3000>BJ^V3000~ HI>DR^795~ HI>BF^V053~ HI>BE^02^^^0>BE^54^^^3175~ HI>BG^09~ QTY>CA>2>DA~ NM1>71>1>TAYLOR>THOMAS>W>>>XX>1619933333~ REF>1G>G99888~ LX>1~ SV2>0171>>1730>DA>2>865~ LX>2~ SV2>0250>>110.64>UN>3~ LX>3~ SV2>0301>>209.1>UN>8~ HL>4>>20>1~ PRV>BI>ZZ>333A00000X~ NM1>85>2>JASONS HEALTH CAMPUS>>>>>XX>5555555555~ N3>794 2ND ST~ N4>ROUND LAKE>IL>60054~ REF>1A>1F11HHE~ REF>EI>411599999~ PER>IC>JASONS HEALTH CAMPUS>TE>8479419218>FX>0000000000~ NM1>87>2>JASONS HEALTH CAMPUS>>>>>XX>5555555555~ N3>NW 150 PO BOX 1234~ N4>VERNON HILLS>IL>60061~ REF>EI>411599999~ HL>5>4>22>1~ SBR>P>>EP111ZA>>>>>>BL~ NM1>IL>1>SPENCER>JANE>L>>>MI>XZAXZ2222222~ N3>7382 COCONUT AVE S~ N4>DEERPARK>IL>60055~ DMG>D8>19560130>F~ NM1>PR>2>BLUE PLUS G>>>>>PI>1513~ N3>P O BOX 47594~ N4>CHICAGO>IL>60063~ NM1>QD>1>SPENCER>WILLIAM>D~ N3>7382 COCONUT AVE S~ N4>DEERPARK>IL>60055~ HL>6>5>23>0~ PAT>01~ NM1>QC>1>SPENCER>WILLIAM>D~ N3>7382 COCONUT AVE S~ N4>DEERPARK>IL>60055~ DMG>D8>19420324>M~ CLM>01234568>4757.5>>>13^A^3>N>A>Y>Y>>>>>>>>>N~ DTP>434>RD8>20080320-20080320~ DTP>435>DT>200803200700~ CL1>3>1>30~ REF>EA>018222222~ HI>BK^28731~ HI>BF^1579~ HI>BG^09~ NM1>71>1>CAMPBELL>PUNEET>S>>>XX>1841244444~ REF>1G>H62626~ LX>1~ SV2>0250>>130.34>UN>4~ DTP>472>D8>20080320~ LX>2~ SV2>0250>HC^J0610>45.96>UN>4~ DTP>472>D8>20080320~ LX>3~ SV2>0300>HC^36415>37.4>UN>1~ DTP>472>D8>20080320~ LX>4~ SV2>0301>HC^80048>266>UN>1~ DTP>472>D8>20080320~ LX>5~ SV2>0301>HC^83721>66.5>UN>1~ DTP>472>D8>20080320~ LX>6~ SV2>0305>HC^85027>140>UN>1~ DTP>472>D8>20080320~ LX>7~ SV2>0390>HC^P9017>194>UN>1~ DTP>472>D8>20080320~ LX>8~ SV2>0390>HC^P9017^91>1746>UN>9~ DTP>472>D8>20080320~ LX>9~ SV2>0949>HC^36514>2131.3>UN>1~ DTP>472>D8>20080320~ SE>124>0005~ GE>5>11111111~ IEA>1>987654321~