<?xml version="1.0" encoding="Windows-1252" standalone="yes" ?>
<RootData>
    <Claim>
        <TypeOfService>M</TypeOfService>
        <ServiceTypeCde>S</ServiceTypeCde>
        <ExtServicingDoctor>229596QX</ExtServicingDoctor>
        <Voucher>
            <BenefitAssignmentAuthorised>Y</BenefitAssignmentAuthorised>
            <ExternalInvoice>PPINV00001</ExternalInvoice>
            <ExternalPatientId>EXTERNAL1</ExternalPatientId>
            <PatientFamilyName>Gump</PatientFamilyName>
            <PatientFirstName>Forrest</PatientFirstName>
            <PatientMiddleName>M</PatientMiddleName>
            <PatientDateOfBirth>30/12/1945</PatientDateOfBirth>
            <PatientGender>M</PatientGender>
            <PatientMedicareCardNum>2111-1111-1</PatientMedicareCardNum>
            <PatientReferenceNum>1</PatientReferenceNum>
            <ReferringProviderNum>123456AF</ReferringProviderNum>
            <RefDrFirstName>Pete</RefDrFirstName>
            <RefDrLastName>Pan</RefDrLastName>
            <RequestTypeCde>D</RequestTypeCde>
            <ReferralIssueDate>13/07/2016</ReferralIssueDate>
			<ReferralPeriod>12</ReferralPeriod>
            <ReferralOverrideTypeCde></ReferralOverrideTypeCde>
            <LSPNum>0001</LSPNum>
		    <HospitalInd></HospitalInd>
			<FacilityId></FacilityId>
            <NumberItems>2</NumberItems>
            <DateOfService>17/12/2016</DateOfService>
       	    <TimeOfService>1400</TimeOfService>
            <Service>
                <ItemNum>57521</ItemNum>
                <RestrictiveOverrideCde>NC</RestrictiveOverrideCde>
                <ServiceText>left knee</ServiceText>
                <DuplicateServiceOverrideInd>Y</DuplicateServiceOverrideInd>
            </Service>
            <Service>
                <ItemNum>57521</ItemNum>
                <RestrictiveOverrideCde>NC</RestrictiveOverrideCde>
                <ServiceText>right knee</ServiceText>
                <DuplicateServiceOverrideInd>Y</DuplicateServiceOverrideInd>
            </Service>
        </Voucher>
    </Claim>
    <Claim>
        <TypeOfService>M</TypeOfService>
        <ServiceTypeCde>S</ServiceTypeCde>
        <ExtServicingDoctor>229596QX</ExtServicingDoctor>
        <Voucher>
            <BenefitAssignmentAuthorised>Y</BenefitAssignmentAuthorised>
            <ExternalInvoice>PPINV00002</ExternalInvoice>
            <ExternalPatientId>EXTERNAL1</ExternalPatientId>
            <PatientFamilyName>Gump</PatientFamilyName>
            <PatientFirstName>Forrest</PatientFirstName>
            <PatientMiddleName>M</PatientMiddleName>
            <PatientDateOfBirth>30/12/1945</PatientDateOfBirth>
            <PatientGender>M</PatientGender>
            <PatientMedicareCardNum>2111-1111-1</PatientMedicareCardNum>
            <PatientReferenceNum>1</PatientReferenceNum>
            <ReferringProviderNum>123456AF</ReferringProviderNum>
            <RefDrFirstName>Pete</RefDrFirstName>
            <RefDrLastName>Pan</RefDrLastName>
            <RequestTypeCde>D</RequestTypeCde>
            <ReferralIssueDate>13/07/2016</ReferralIssueDate>
			<ReferralPeriod>12</ReferralPeriod>
            <ReferralOverrideTypeCde></ReferralOverrideTypeCde>
            <LSPNum>0001</LSPNum>
		    <HospitalInd></HospitalInd>
			<FacilityId></FacilityId>
            <BClmAmt></BClmAmt>
            <NumberItems>2</NumberItems>
        	<TimeOfService>1400</TimeOfService>
            <DateOfService>15/12/2016</DateOfService>
            <Service>
                <ItemNum>57509</ItemNum>
                <RestrictiveOverrideCde>NC</RestrictiveOverrideCde>
                <ServiceText>left hand</ServiceText>
                <DuplicateServiceOverrideInd>Y</DuplicateServiceOverrideInd>
    	        <TimeOfService>1400</TimeOfService>
            </Service>
            <Service>
                <ItemNum>57509</ItemNum>
                <RestrictiveOverrideCde>NC</RestrictiveOverrideCde>
                <ServiceText>right hand</ServiceText>
                <DuplicateServiceOverrideInd>Y</DuplicateServiceOverrideInd>
            </Service>
        </Voucher>
    </Claim>
</RootData>
