HIPAA 5010 834 Benefit Enrollment

ISA*00*          *00*          *ZZ*386028429      *30*382328142      *050221*0602*U*00501*000012345*0*P*:~
GS*BE*386028429*382328142*20050221*0602*000012345*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000012345~
IEA*1*000012345~
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