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COLLEGE HOSPITAL 1150748001. 4500 BROAD AVENUE 112. WOODLAND HILLS XY 12345-0000 12. 555 487 6789 951690976 62520XX 62520XX. Patient ID if different from Sub 1402 12 TH PLACE WOODLAND HILLS XY 12345. SOUZA JAMES. 08211994 M 081220XX 19 2 4 11 30 CI 1234.
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COLLEGE HOSPITAL 1150748001 4500 BROAD AVENUE 112 WOODLAND HILLS XY 12345-000012 555 487 6789951690976 62520XX 62520XX Patient ID if different from Sub1402 12TH PLACE WOODLAND HILLS XY 12345 SOUZA JAMES 08211994 M 081220XX 19 2 4 11 30 CI 1234 A A SOUZA JAMES 1402 12TH PLACE WOODLAND HILLS XY 12345 01 804 00 02 100 00 03 100 00 01 804 00 02 100 00 03 100 00 01 804 00 02 100 00 03 100 00 01 804 00 02 100 00 03 100 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 NEONATAL ICU 184400 14 25816 00 175 1 2 01/12/2010 25816 00 ADSFSADDFSA Tricare 1324321413242 A A 123 00 1234 00 ADSFSADDFSA Tricare 1324321413242 A A 123 00 1234 00 ADSFSADDFSA Tricare 1324321413242 A A 123 00 1234 00 ADSFSADDFSA Primary A 123434343 QQWERFFAAAWQDF Secondary A 123434343 QQWERFFAAAWQDF Third A 123434343 QQWERFFAAAWQDF 02468 ASDFVCVS120987987 Acme 02468 ASDFVCVS120987987 Acme 02468 ASDFVCVS120987987 Acme 12345 12345 12345 12345 12345 12345 12345 12345 12345 RESERVED 9 12345 12345 12345 12345 12345 12345 12345 12345 12345 RESERVED 4280 111 1234 1234 DRG 12345 12345 12345 RESERVED 1234567890 22 1234569822 37490 012011 12345 12345 12345 12345 SMITH JOHN 1234567890 22 1234569822 37490 012011 12345 12345 12345 12345 SMITH JOHN B3 282N00000X 112343214243 22 1234567890 22 1234569822 REMARKS B3 282N00000X 112343214243 SMITH JOHN REMARKS B3 282N00000X 112343214243 22 1234567890 22 1234569822 REMARKS B3 282N00000X 112343214243 SMITH JOHN
