| Entire Segment |
| ST*837*1 |
| BHT*0019*00*868-0-0-1*20030722*114945*CH |
| REF*87*004010X098 |
| NM1*41*2*Social Provider*****46*445566778 |
| PER*IC*Administrator*TE*6106876080*EX*111 |
| NM1*40*2*Institution of Welfare*****46*998877665 |
| HL*1**20*1 |
| PRV*BI*ZZ*101YM0800X |
| NM1*85*2*Social Provider*****24*199999999 |
| N3*1234 Good Street |
| N4*Philadelphia*PA*59128 |
| REF*1C*ZZ908008 |
| HL*2*1*22*1 |
| SBR*P********MB |
| NM1*IL*1*Doesubscrib*John****MI*3000000003 |
| N3*Subscribe Drive |
| N4*Philadelphia*PA*49125 |
| DMG*D8*19400303*M |
| NM1*PR*2*Community Social Health*****PI*ZZ432678 |
| N3*714 Market Street |
| N4*Philadelphia*PA*49106 |
| HL*3*2*23*0 |
| PAT*01 |
| NM1*QC*1*Doedepend*Joe |
| N3*307 Dependant Street |
| N4*Philadelphia*PA*49125 |
| DMG*D8*3/3/1950*M |
| REF*SY*333333333 |
| CLM*62672*22.5***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*22.5*UN*3***1**N |
| DTP*472*D8*20030328 |
| REF*G1*1968342 |
| CLM*63325*147***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*147*UN*12***1**N |
| DTP*472*D8*20030404 |
| REF*G1*1968341 |
| CLM*63593*15***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*15*UN*2***1**N |
| DTP*472*D8*20030401 |
| REF*G1*1968342 |
| CLM*65119*147***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*147*UN*12***1**N |
| DTP*472*D8*20030408 |
| REF*G1*1968341 |
| CLM*65411*60***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*60*UN*8***1**N |
| DTP*472*D8*20030409 |
| REF*G1*1968342 |
| CLM*65901*147***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*147*UN*12***1**N |
| DTP*472*D8*20030415 |
| REF*G1*1968341 |
| CLM*62437*147***11::1*Y*A*Y*Y*C |
| HI*BK:V7389 |
| LX*1 |
| SV1*HC:87073*147*UN*12***1**N |
| DTP*472*D8*20030324 |
| REF*G1*1968341 |
| SE*71*1 |