<?xml version="1.0" encoding="Windows-1252" standalone="yes" ?>
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        <TypeOfService>PC</TypeOfService>
        <ServiceTypeCde>P</ServiceTypeCde>
        <ExtServicingDoctor>060174DB</ExtServicingDoctor>
        <SenderId></SenderId>
        <RecipientId></RecipientId>
        <Voucher>
            <LabReferral></LabReferral>
            <ClaimSubmissionAuthorised>Y</ClaimSubmissionAuthorised>
            <ExternalPatientId>HP0182486</ExternalPatientId>
            <ExternalInvoice>H17-025840</ExternalInvoice>
            <ClaimantAddressLine1>123 Test St</ClaimantAddressLine1>
			<ClaimantAddressLine2>Tester</ClaimantAddressLine2>
            <ClaimantAddressLocality>Darlington</ClaimantAddressLocality>
            <ClaimantAddressPostcode>1234</ClaimantAddressPostcode>
            <ClaimantDateOfBirth>01/01/1990</ClaimantDateOfBirth>
			<ClaimantAddressState>NSW</ClaimantAddressState>
			<ClaimantPhone>0412345678</ClaimantPhone>
            <ClaimantFamilyName>John</ClaimantFamilyName>
            <ClaimantFirstName>Smith</ClaimantFirstName>
            <ClaimantMedicareCardNum>2111-11111-1</ClaimantMedicareCardNum>
            <ClaimantReferenceNum>1</ClaimantReferenceNum>
            <PatientFamilyName>Smith</PatientFamilyName>
            <PatientFirstName>Michael</PatientFirstName>
            <PatientMiddleName></PatientMiddleName>
            <PatientDateOfBirth>21/09/1952</PatientDateOfBirth>
            <PatientGender>F</PatientGender>
            <PatientAddressLine>24  Linden Street</PatientAddressLine>
            <PatientAddressLocality>FAIRFIELD</PatientAddressLocality>
            <PatientAddressPostcode>2165</PatientAddressPostcode>
            <PatientMedicareCardNum>2952627491</PatientMedicareCardNum>
            <PatientReferenceNum>1</PatientReferenceNum>
            <DateOfService>29/06/2017</DateOfService>
            <TimeOfService></TimeOfService>
            <ReferringProviderNum>2423831W</ReferringProviderNum>
            <ReferralIssueDate>29/06/2017</ReferralIssueDate>
			<ReferralPeriod>12</ReferralPeriod>
            <SCPId>A01</SCPId>
            <HospitalInd>Y</HospitalInd>
			<FacilityId>9988770W</FacilityId>
            <NumberItems>2</NumberItems>
            <RefDrFirstName>Dr Peter</RefDrFirstName>
            <RefDrLastName>Campbell</RefDrLastName>
            <RefDrSuburb>LIVERPOOL</RefDrSuburb>
            <RefDrAddress>Suite 11, Level 1</RefDrAddress>
            <RefDrState>NSW</RefDrState>
            <RefDrPostcode>2170</RefDrPostcode>
            <RefDrPhone>9822 5033</RefDrPhone>
            <RefDrEmail></RefDrEmail>
            <LabReferral>N</LabReferral>
            <Service>
                <ItemNum>72824</ItemNum>
                <DuplicateServiceOverrideInd></DuplicateServiceOverrideInd>
                <Rule3ExemptInd></Rule3ExemptInd>
                <S4b3ExemptInd></S4b3ExemptInd>
                <AccessionDateTime>290620171420</AccessionDateTime>
                <ServiceText>9988770W</ServiceText>
                <ChargeAmount>100</ChargeAmount>
				<PaidAmount>100</PaidAmount>
            </Service>
            <Service>
                <ItemNum>72856</ItemNum>
                <DuplicateServiceOverrideInd></DuplicateServiceOverrideInd>
                <Rule3ExemptInd></Rule3ExemptInd>
                <S4b3ExemptInd></S4b3ExemptInd>
                <AccessionDateTime>290620171420</AccessionDateTime>
                <ServiceText>9988770W</ServiceText>
                <ChargeAmount>100</ChargeAmount>
				<PaidAmount>100</PaidAmount>
            </Service>
        </Voucher>
    </Claim>
</RootData>
