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Text File  |  1990-10-15  |  4KB  |  16 lines
  1.   *** THIS IS ONLY A SAMPLE - DO NOT SUBMIT ***                                                                                                                                                                                                 
  2. B0                                                               7185551212TEST              ANY STREET 1234567NEW CITY ABCDEF  111111111DOCTOR-ABCDEFGHIJKLMTEST NAMEXX                                                                        
  3. C0  9091961000       PATIENT             JOHN      F109091961M    999 TRANS WEST AVE                  WEST END CITY    9999900009165551212      Y                                                                                               
  4. D0                                              9091961000          GHI              PATIENT             JOHN      F     Y                                                                                                                      
  5. D1  999 TRANS WEST AVE                  WEST END CITY    999990000                                                                                    9165551212                                                                                
  6. E0  V                                                                                                                                                                                                                                           
  7. F001          013     46255     01100000      ############                   013     46255     02100000      ############                   013     46255     03100000      ############                                                        
  8. J0            *                                                                                                                                                                                                                                 
  9. F002          013     46255     04100000      ############                   013     46255     05100000      ############                   013     46255     06100000      ############                                                        
  10. F003          013     46255     07100000      ############                   013     46255     08100000      ############                   013     46255     09100000      ############                                                        
  11. F004          013     46255     10100000      ############                   013     46255     11100000      ############                   013     46255     12100000      ############                                                        
  12. F005          013     46255     13100000      ############                   013     46255     14100000      ############                   013     46255     15100000      ############                                                        
  13. N0                                                                      000000000000000000                                                                                                                                                      
  14. X0  01301020105000100001501500000        01500000                                                                                                                                                                                               
  15. 8                                                                                                                                                                                                                                               
  16.