<?xml version="1.0" encoding="Windows-1252" standalone="yes" ?>
<RootData>
    <Claim>
        <TypeOfService>V</TypeOfService>
        <ServiceTypeCde>P</ServiceTypeCde>
        <ExtServicingDoctor>229596QX</ExtServicingDoctor>
        <Voucher>
            <ExternalInvoice>PPINV00001</ExternalInvoice>
            <ExternalPatientId>EXTERNAL1</ExternalPatientId>
            <PatientFamilyName>Gump</PatientFamilyName>
            <PatientFirstName>Forrest</PatientFirstName>
            <PatientMiddleName>M</PatientMiddleName>
            <PatientDateOfBirth>30/12/1945</PatientDateOfBirth>
            <PatientGender>F</PatientGender>
            <VeteranFileNum>NX123456</VeteranFileNum>
            <ReferringProviderNum>123456AF</ReferringProviderNum>
            <RefDrFirstName>Pete</RefDrFirstName>
            <RefDrLastName>Sampras</RefDrLastName>
            <ReferralIssueDate>13/07/2016</ReferralIssueDate>
            <ReferralPeriodTypeCde>S</ReferralPeriodTypeCde>
            <ReferralPeriod>12</ReferralPeriod>
            <SCPId>A01</SCPId>
			<FacilityId></FacilityId>
            <NumberItems>01</NumberItems>
            <DateOfService>17/12/2016</DateOfService>
            <TimeOfService></TimeOfService>
            <BenefitAssignmentAuthorised>Y</BenefitAssignmentAuthorised>
            <TreatmentLocationCde></TreatmentLocationCde>
            <Service>
                <ItemNum>72848</ItemNum>
                <Rule3ExemptInd>N</Rule3ExemptInd>
                <S4b3ExemptInd>N</S4b3ExemptInd>
                <CollectionDateTime></CollectionDateTime>
                <AccessionDateTime></AccessionDateTime>
                <ServiceText></ServiceText>
            </Service>
        </Voucher>
    </Claim>
</RootData>
