Patient Information (X210)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240222*0142*^*00501*000000001*0*T*>~
GS*PI*SENDERGS*RECEIVERGS*20240222*014254*000000001*X*005010X210~
ST*275*1001*005010X210~
BGN*11*0001*20060915~
NM1*PR*2*ABC INSURANCE COMPANY*****XV*12345~
NM1*41*2*XYZ SERVICES*****46*A222222221~
NM1*1P*2*ST HOLY HILLS HOSPITAL*****XX*3999000B01~
NX1*1P~
N3*2345 Winter Blvd~
N4*Miami*FL*33132~
NM1*QC*1*JACKSON*JACK*J***MI*987654320~
REF*EJ*JACKSON123~
REF*EA*STHHL12345~
DTP*472*D8*20060812~
LX*1~
TRN*2*1822634840~
STC*R4>18626-2>>LOI~
DTP*368*D8*20060915~
CAT*AE*TX~
EFI*05~
BIN*6*......~
LX*2~
TRN*2*1822634840~
STC*R4>18647-8>>LOI~
DTP*368*D8*20060915~
CAT*AE*TX~
EFI*05~
BIN*6*......~
SE*27*1001~
GE*1*000000001~
IEA*1*000000001~

Example 1: Electronic Request

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240222*0149*^*00501*000000001*0*T*>~
GS*PI*SENDERGS*RECEIVERGS*20240222*014957*000000001*X*005010X210~
ST*275*1001*005010X210~
BGN*02*0001*20060918~
NM1*PR*2*ABC INSURANCE COMPANY*****XV*12345~
NM1*41*2*XYZ SERVICES*****46*A222222221~
NM1*1P*2*ST HOLY HILLS HOSPITAL*****XX*3999000801~
NX1*1P~
N3*2345 Winter Blvd~
N4*Miami*FL*33132~
NM1*QC*1*JACKSON*JACK*J***MI*987654323~
REF*EJ*JACKSON123~
REF*EA*STHHL12345~
DTP*472*D8*20060915~
LX*1~
TRN*1*986543~
DTP*368*D8*20060918~
CAT*AE*HL~
EFI*05~
BIN*4*1101~
SE*19*1001~
GE*1*000000001~
IEA*1*000000001~

X12 275 Patient Information (X210)