ISA*00*          *00*          *ZZ*M00044SC1      *ZZ*SCMEDICAID     *110209*1327*U*00401*100000880*1*P*:~
GS*HC*M00044SC1*SCMEDICAID*20110209*1327*1070*X*004010X098A1~
ST*837*0001~
BHT*0019*00*1615*20110209*1327*CH~
REF*87*004010X098A1~
NM1*41*2*ANDERSON SCHOOL DISTRICT THREE*****46*M00044SC1~
PER*IC*CHARLENE POWELL*TE*8643486196*EX*10*EM*POWELLC@ANDERSON3.K12.SC.US~
NM1*40*2*SCMEDICAID*****46*SCMEDICAID~
HL*1**20*1~
NM1*85*2*ANDERSON SCHOOL DISTRICT THREE*****XX*1467406462~
N3*P. O. BOX 118~
N4*IVA*SC*29655~
REF*1D*SD0403~
REF*EI*576001050~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*BARNES*KILLIAN*J***MI*0781241340~
N3*201 BROADWELL MILL ROAD~
N4*ANDERSON*SC*29626~
DMG*D8*20041209*M~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22664*38.10***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31401~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101207~
REF*6R*98575~
LX*2~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101208~
REF*6R*98576~
NM1*82*1*HUGHES*BETH****24*576001050~
SE*194*0001~
ST*837*0002~
BHT*0019*00*1615*20110209*1327*CH~
REF*87*004010X098A1~
NM1*41*2*ANDERSON SCHOOL DISTRICT THREE*****46*M00044SC1~
PER*IC*CHARLENE POWELL*TE*8643486196*EX*10*EM*POWELLC@ANDERSON3.K12.SC.US~
NM1*40*2*SCMEDICAID*****46*SCMEDICAID~
HL*1**20*1~
NM1*85*2*ANDERSON SCHOOL DISTRICT THREE*****XX*1467406462~
N3*P. O. BOX 118~
N4*IVA*SC*29655~
REF*1D*SD0403~
REF*EI*576001050~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*BARNES*KILLIAN*J***MI*0781241340~
N3*201 BROADWELL MILL ROAD~
N4*ANDERSON*SC*29626~
DMG*D8*20041209*M~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22664*38.10***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31401~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101207~
REF*6R*98575~
LX*2~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101208~
REF*6R*98576~
NM1*82*1*HUGHES*BETH****24*576001050~
SE*194*0002~
ST*837*0003~
BHT*0019*00*1615*20110209*1327*CH~
REF*87*004010X098A1~
NM1*41*2*ANDERSON SCHOOL DISTRICT THREE*****46*M00044SC1~
PER*IC*CHARLENE POWELL*TE*8643486196*EX*10*EM*POWELLC@ANDERSON3.K12.SC.US~
NM1*40*2*SCMEDICAID*****46*SCMEDICAID~
HL*1**20*1~
NM1*85*2*ANDERSON SCHOOL DISTRICT THREE*****XX*1467406462~
N3*P. O. BOX 118~
N4*IVA*SC*29655~
REF*1D*SD0403~
REF*EI*576001050~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*BARNES*KILLIAN*J***MI*0781241340~
N3*201 BROADWELL MILL ROAD~
N4*ANDERSON*SC*29626~
DMG*D8*20041209*M~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22664*38.10***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31401~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101207~
REF*6R*98575~
LX*2~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101208~
REF*6R*98576~
NM1*82*1*HUGHES*BETH****24*576001050~
SE*194*0003~
GE*3*1070~
IEA*1*100000880~
