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        <ExtServicingDoctor>459103VB</ExtServicingDoctor>
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            <BenefitAssignmentAuthorised>Y</BenefitAssignmentAuthorised>
            <ExternalPatientId>21112016020800039</ExternalPatientId>
            <ExternalInvoice>316852252</ExternalInvoice>
            <PatientFamilyName>Sampras</PatientFamilyName>
            <PatientFirstName>Peter</PatientFirstName>
            <PatientDateOfBirth>10/03/1949</PatientDateOfBirth>
            <PatientMedicareCardNum>2111-11111-1</PatientMedicareCardNum>
            <PatientReferenceNum>1</PatientReferenceNum>
            <DateOfService>28/11/2016</DateOfService>
			<TimeOfService>1400</TimeOfService>			
            <ReferringProviderNum>123456AF</ReferringProviderNum>
            <ReferralIssueDate>07/11/2016</ReferralIssueDate>
            <ReferralPeriod>12</ReferralPeriod>
            <NumberItems>3</NumberItems>
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                <ItemNum>304</ItemNum>
                <NoOfPatientsSeen>1</NoOfPatientsSeen>
                <SelfDeemedCde>N</SelfDeemedCde>
                <MultipleProcedureOverrideInd>N</MultipleProcedureOverrideInd>
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                <SelfDeemedCde>N</SelfDeemedCde>
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                <ChargeAmount></ChargeAmount>
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            <Service>
                <ItemNum>288</ItemNum>
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                <SelfDeemedCde>N</SelfDeemedCde>
                <MultipleProcedureOverrideInd>N</MultipleProcedureOverrideInd>
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