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        <ServiceTypeCde>P</ServiceTypeCde>
        <ExtServicingDoctor>229596QX</ExtServicingDoctor>
        <Voucher>
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            <PatientMiddleName>M</PatientMiddleName>
            <PatientDateOfBirth>30/12/1945</PatientDateOfBirth>
            <PatientGender>F</PatientGender>
            <PatientMedicareCardNum>2111-1111-1</PatientMedicareCardNum>
            <PatientReferenceNum>1</PatientReferenceNum>
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            <RefDrFirstName>Pete</RefDrFirstName>
            <RefDrLastName>Sampras</RefDrLastName>
            <ReferralIssueDate>13/07/2016</ReferralIssueDate>
            <ReferralPeriod>12</ReferralPeriod>
            <RequestTypeCde>P</RequestTypeCde>
            <SCPId>A01</SCPId>
			<HospitalInd>Y</HospitalInd>
			<FacilityId>123456AF</FacilityId>
            <NumberItems>01</NumberItems>
            <DateOfService>17/12/2016</DateOfService>
            <TimeOfService></TimeOfService>
            <BenefitAssignmentAuthorised>Y</BenefitAssignmentAuthorised>
            <Service>
                <ItemNum>72848</ItemNum>
                <Rule3ExemptInd>N</Rule3ExemptInd>
                <S4b3ExemptInd>N</S4b3ExemptInd>
                <CollectionDateTime></CollectionDateTime>
                <AccessionDateTime></AccessionDateTime>
                <ServiceText>123456AF</ServiceText>
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    </Claim>
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