The following is a sample HIPAA document in Electronic Data Interchange (EDI) format. Shown in the next two topics are the acknowledgement and XML file that are generated from this HIPAA document on a channel configured for inbound processing.

The interchange (ISA) is 106 characters fixed length, but it has been reformatted here to fit on the page.

ISA*00*1234567890*00*1234567890*ZZ*SUBMITTERS ID12*ZZ*RECEIVERS ID123*010122*1253*U*00401*000000905*1*T*:
GS*HS*SenderID*ReceiverID*20010122*1310*1*X*004010X092A1
ST*270*1234
BHT*0022*13*10001234*19990501*1319
HL*1**20*1
NM1*PR*2*ABCCOMPANY*****PI*842610001
HL*2*1*21*1
NM1*1P*1*JONES*MARCUS****SV*0202034
REF*N5*129
N3*55 HIGH STREET
N4*SEATTLE*NY*10121
PER*IC*MARYMURPHY*TE*2065551212*EX*3694*FX*2065551214
HL*3*2*22*1
NM1*IL*1*SMITH*ROBERT*B***MI*11122333301
REF*1L*599119
N3*29 FREMONT ST*APT# 1
N4*PEACE*NY*10023
DMG*D8*19430519*M
HL*4*3*23*0
TRN*1*93175-012547*9877281234*RADIOLOGY
NM1*03*1*SMITH*MARYLOU
REF*SY*003221234
N3*29 FREMONT ST*APT# 1
N4*PEACE*NY*10023
DMG*D8*19781014*F
DTP*472*D8*19990501
EQ*81**FAM
SE*26*1234
GE*1*1
IEA*1*000000905