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GS*HI*PARTICIPANTID*PAYER123*20060424*1244*17*X*005010X217
ST*278*1234*005010X217
BHT*0007*13*123*20060424*1244
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NM1*PR*2*AETNA 1234560010*****PI*PAYER123
HL*2*1*21*1
NM1*1P*1*POPDELL*ROBERT****24*4376557IM
PER*IC**TE*6515551212*FX*6513332222
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NM1*IL*1*SMITH*SARA****MI*352584768003G
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HL*4*3*EV*1
UM*HS*I*88
PWK*04*EL***AC*JONP56789001
HL*5*4*SS*0
SV1*N4>0173042304
MSG* Oxistat Cream, 1%, 60 gram tube
SE*18*1234
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NM1*1P*1*POPDELL*ROBERT****24*4376557IM
NM1*PR*2*AETNA 1234560010*****PI*PAYER123
NM1*IL*1*SMITH*SARA****MI*352584768003G
LX*1
TRN*1*JONP56789001
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CAT*AE*HL
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BIN*4896*<levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3/cda levelone_1.0.attachments.xsd">
<clinical_document_header>
<id EX="a123" RT="2.16.840.1.113883.3.933"/>
<document_type_cd V="99999-7" DN="Imidazole-Related Antifungals Attachment"/>
<origination_dttm V="2006-01-05"/>
<provider>
<provider.type_cd V="PRF"/>
<person>
<id EX="4376557IM" RT="2.16.840.1.113883.19.10.1"/>
<person_name>
<nm>
<v3dt:GIV V="Robert"/>
<v3dt:MID V="J"/>
<v3dt:FAM V="Podell"/>
<v3dt:SFX V="MD"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/>
</person_name>
</person>
</provider>
<patient>
<patient.type_cd V="PATSBJ"/>
<person>
<id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/>
<person_name>
<nm>
<v3dt:GIV V="Sara"/>
<v3dt:MID V="J"/>
<v3dt:FAM V="Smith"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.12.200"/>
</person_name>
</person>
<is_known_by>
<id EX="184569" RT="2.16.840.1.1138863.19.10.3"/>
<is_known_to>
<id EX="352584768003G" RT="2.16.840.1.113883.19.10.2"/>
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</is_known_by>
</patient>
<local_header descriptor="Att_ACN">
<local_attr name="attachment_control_number" value="XA728302"/>
</local_header>
</clinical_document_header>
<body>
<section>
<caption>PRESCRIBER INFORMATION</caption>
<paragraph>
<caption>PRESCRIBER INFORMATION, NAME</caption>
<content>Robert J. Podell, MD</content>
</paragraph>
<paragraph>
<caption>PRESCRIBER INFORMATION, IDENTIFIER</caption>
<content>4376557IM</content>
</paragraph>
<paragraph>
<caption>PRESCRIBER INFORMATION, SPECIALTY TAXONOMY</caption>
<content>Hepatologist (207RI0008X)</content>
</paragraph>
</section>
<section>
<caption>PRESCRIBER CONTACT INFORMATION</caption>
<paragraph>
<caption>PRESCRIBER CONTACT INFORMATION, PHONE NUMBER</caption>
<content>(765) 228-1234</content>
</paragraph>
<paragraph>
<caption>PRESCRIBER CONTACT INFORMATION, FAX NUMBER</caption>
<content>(765) 228-3123</content>
</paragraph>
</section>
<section>
<caption>DRUG PRESCRIBED</caption>
<paragraph>
<caption>DRUG PRESCRIBED, NAME</caption>
<content>Oxistat Cream, 1%, 60g tube</content>
</paragraph>
<paragraph>
<caption>DRUG PRESCRIBED, DRUG CODE</caption>
<content>0173-0423-04 (NDC)</content>
</paragraph>
<paragraph>
<caption>DRUG PRESCRIBED, THERAPY TYPE</caption>
<content>Replacement (RPLRQ)</content>
</paragraph>
</section>
<section>
<caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS</caption>
<paragraph>
<caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG NAME</caption>
<content>Tinactin Cream</content>
</paragraph>
<paragraph>
<caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DRUG CODE</caption>
<content>0085-0715-07 (NDC)</content>
</paragraph>
<paragraph>
<caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - DURATION OF THERAPY</caption>
<content>90 days</content>
</paragraph>
<paragraph>
<caption>DRUG HISTORY, PRIOR THERAPY FOR DIAGNOSIS - REASON PRIOR THERAPY DISCONTINUED</caption>
<content>Not or no longer effective (NTEFF)</content>
</paragraph>
</section>
<section>
<caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS</caption>
<paragraph>
<caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS</caption>
<content>Tinea Pedia (ICD-9-CM 110.4)</content>
</paragraph>
<paragraph>
<caption>IMIDAZOLE-RELATED ANTIFUNGALS, RELATED DIAGNOSIS - CONFIRMED BY</caption>
<content>KOH Preparation (KOH)</content>
</paragraph>
</section>
<section>
<caption>FUNGAL INFECTION LOCATION</caption>
<paragraph>
<content>Between Toes, right foot (OTH)</content>
</paragraph>
</section>
<section>
<caption>DRUG PRESCRIBED, REASON FOR TOPICAL THERAPY</caption>
<paragraph>
<content>Hepatic Dysfunction (HDS)</content>
</paragraph>
</section>
<section>
<caption>CO-MORBID CONDITION INFORMATION</caption>
<paragraph>
<caption>CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION INDICATOR</caption>
<content>yes (Y)</content>
</paragraph>
<paragraph>
<caption>CO-MORBID CONDITION INFORMATION, LIVER DYSFUNCTION CONFIRMED BY</caption>
<content>Hepatic Function Panel (HFP)</content>
</paragraph>
</section>
<section>
<caption>MEDICARE ESRD CERTIFICATION INDICATOR</caption>
<paragraph>
<content>Yes (Y)</content>
</paragraph>
</section>
<section>
<caption>IMIDAZOLE-RELATED ANTIFUNGALS, PRIOR THERAPY TYPE</caption>
<paragraph>
<content>Topical (TOP)</content>
</paragraph>
</section>
</body>
</levelone>
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GE*1*17
IEA*2*000000017