SCRDO1                      * * * DOCTOR FILE  * * *     A/C/I/END : CHANGE

 1. DOCTOR NUMBER:2

 2. NAME (END)   :WELBY,MARCUS

 3. SHORT NAME   :MW                       10. UPIN #         :A88455

 4. CAR PHONE    :                         11. INS BILL PLACE :2    0

 5. SOC. SEC. #  :333445555                12. DOCTOR SPECIALTY CODE : 83

 6. STATE LIC. # :G82275                   13. DOCTOR SPECIALTY:Allergy

 7. ADDRESS      :5150 RESERVOIR           14. NPI Provider  # :

 8. CITY,STATE   :SAN DIEGO,CA             15. Champus Prov  # :

 9. ZIP CODE     :92120                    16. OPTIONAL FLAG   :F

SCRHOS              ***  PLACE OF SERVICE FILE  ***      A/C/END: C

 1 PLACE NUMBER 1                       8 BILL INS SEPARATELY? (Y/N): Y

 2 PLACE TYPE   1                       9 CODES FOR INS FORMS: 11 11 11 11 11

 3 NAME1     PLACE ONE                                         11 11 11 11 11

 4 NAME2                               10 Fax :  (858)555-1212

 5 STREET    PO BOX 11111              11 Phone:  (858)555-1234

 6 CTY/ST    SAN DIEGO, CA

 7 ZIP CODE  92120

 *****************************************************************************

15 PROVIDER ID #1  :                   21 MEDICARE MODIFIER:

16 PROVIDER ID #2  :                   22 TAX ID SUFFIX : TLE        TYPE

17 MEDI-CAL PROV # :                   23 GTE-PLACE CODE   :

18 MEDICARE PROV # : W111111           24 GTE-CLAIM CODE   :

19 EMPLOYER ID #   : 111111111         25 CLIA # : 05D0717712

20 NPI Number   :                  26 MEMO             :

REFDOC                     REFERRING DOCTOR FILE         A/C/P/END :

   1.DOCTOR NO. : 2                             7.PHONE     : (858) 274-5565

                                                  FAX Ph #  :

   2.NAME       : BESSER,SUSAN M.D.             8.LICENSE   :

   3.ADDRESS    : 5987 MEDICAL VIEW DR          9.HOSP CODE :

   4.CITY       : SAN DIEGO                    10.SPECIALTY :

   5.STATE      : CA                           11. UPIN #   : 256398

                                               12. TAX ID   :

   6.ZIP        : 92158                        13. NPI #    : 2323332322

                                               20. MEMO     :

On Electronic Hard Copy Report, NPI will print:

Date: 09/20/2006 Time: 07:43 AM  DOCY2K - SAMPLE YEAR 2000 DATA        PAGE    1

                                             **** Electronic Billing Report ****

Beneficiary Name   HIC#       Date of Svc   POS Prc Cde Mod1 Mod2 ICD Code   Charge  Qty   St Lic

-------------------------------------------------------------------------------------------------

Record Code ISA - Header for ANSI Format File: INS302.SAV        ISA Control ID: 000005407 

     Carrier Code:      31146            Ver:004010X098A1        Submitter Address:

     Submitter Code:    000004056                                Submitter City:

     Submitter Name:    ZYBEX BILLING SVC                        Submitter State:

     Attention Line:    CALL PAM 9.6(171) NSFANSI 9.6(140        Submitter Zip:

     Billing Date:      060915                                   Production/Test :  P   

     Receiver :         MEDICARE                                 Receiver Code :    31146           

BATCH NO  FOR PROVID=W111111        

     Provider Name :    PLACE ONE                                Medicare ID  :     W111111        

           Address :    PO BOX 11111                             Prov Tax ID  :

           City    :    SAN DIEGO                                NPI #        :   1234567890

           State   :    CA 921200000  PH:

Record Count=37

APODACA,GILBERT   527105251A   050202-050202 11  99215             4139     $ 150.00  002 ZG77507    

11365 CHARNOCK  Cht:0000106 1  050202-050202 11  99213             4139     $  50.00  001 ZG77507    

LOS ANGELES  CA  900660000

ICD9: 1-4139 :  NPI: 1234567890  CLIA#:05D0717712                     Total $  200.00

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Pgfhos.run   scrhos.scr

Nsfall.run  9.6(171)

Nsfansi.run 9.5(143)

Ansichk.run  9.5(137)

Insedt.run   9.5(133)

Pgfrdr.run   9.5(111)   refdoc.scr