<?xml version="1.0" encoding="Windows-1252" standalone="yes" ?>
<RootData>
    <Claim>
        <TypeOfService>N</TypeOfService>
        <ServiceTypeCde>P</ServiceTypeCde>
        <ExtServicingDoctor>123456AF</ExtServicingDoctor>
        <Voucher>
            <BenefitAssignmentAuthorised>Y</BenefitAssignmentAuthorised>
            <ExternalPatientId>HP0142864</ExternalPatientId>
            <ExternalInvoice>H16-011234</ExternalInvoice>
            <AccidentInd>N</AccidentInd>
            <FacilityId>9988770W</FacilityId>
            <FundBrandId>HCF</FundBrandId>
            <FundPayeeId></FundPayeeId>
            <PatientFundMembershipNum>02564807</PatientFundMembershipNum>
            <FinancialInterestDisclosureInd>N</FinancialInterestDisclosureInd>
            <IFCIssueCde>X</IFCIssueCde>
            <PatientFamilyName>TEST</PatientFamilyName>
            <PatientFirstName>TEST</PatientFirstName>
            <PatientMiddleName></PatientMiddleName>
            <PatientDateOfBirth>20/03/1932</PatientDateOfBirth>
            <PatientGender>M</PatientGender>
            <PatientAddressLine>6 Shadow Street</PatientAddressLine>
            <PatientAddressLocality>Sydney</PatientAddressLocality>
            <PatientAddressPostcode>2001</PatientAddressPostcode>
            <PatientMedicareCardNum>2257205218</PatientMedicareCardNum>
            <PatientReferenceNum>1</PatientReferenceNum>
            <ReferringProviderNum>0274951X</ReferringProviderNum>
            <ReferralIssueDate>29/03/2016</ReferralIssueDate>
			<ReferralPeriod>12</ReferralPeriod>
            <SCPId>A01</SCPId>
            <NumberItems>1</NumberItems>
            <RefDrFirstName>Dr Peter</RefDrFirstName>
            <RefDrLastName>Sampras</RefDrLastName>
            <RefDrSuburb>ST LEONARDS</RefDrSuburb>
            <RefDrAddress></RefDrAddress>
            <RefDrState></RefDrState>
            <RefDrPostcode></RefDrPostcode>
            <RefDrPhone></RefDrPhone>
            <RefDrEmail></RefDrEmail>
            <Service>
                <ItemNum>72848</ItemNum>
                <DuplicateServiceOverrideInd></DuplicateServiceOverrideInd>
                <ServiceText></ServiceText>
                <Rule3ExemptInd></Rule3ExemptInd>
                <S4b3ExemptInd></S4b3ExemptInd>
                <CollectionDateTime>011220161200</CollectionDateTime>
                <AccessionDateTime>011220161300</AccessionDateTime>
                <DateOfService>01/01/2017</DateOfService>
                <ChargeAmount>50.00</ChargeAmount>
            </Service>
        </Voucher>
    </Claim>
</RootData>
