ISA*00*

*00*
*ZZ*300780099
*ZZ*582574363
*131203*093
2*^*00501*000000632*0*P*:~GS*HC*300780099*582574363*20131203*0932*632*X*005010X2
22A1~ST*837*000000632*005010X222A1~BHT*0019*00*000632*20131203*0932*CH~NM1*41*2*
DONALD D BACON MD PA*****46*300780099~PER*IC*TINA BATTEN-BAKER*TE*8308379329~NM1
*40*2*NAVICURE*****46*582574363~HL*1**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*
1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*
300780099~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*GARCIA*RONNIE*L***MI*458745814A
~N3*1035 UTOPIA~N4*SAN ANTONIO*TX*78223~DMG*D8*19460911*M~NM1*PR*2*MEDICARE*****
PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2352*295***
11:B:1*Y*A*Y*Y~DTP*431*D8*20131007~REF*X4*45D2058148~REF*EA*GARRON0001~HI*BK:338
28*BF:34601*BF:3501*BF:7238*BF:7231~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*
82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*742836******C
I~OI***Y***Y~NM1*IL*1*GARCIA*RONNIE*L***MI*808859055~N3*1035 UTOPIA~N4*SAN ANTON
IO*TX*78223~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO BOX 30557~N4*SALT LAK
E CITY*UT*841300557~SBR*T*18*NONE******CI~OI***Y***Y~NM1*IL*1*GARCIA*RONNIE*L***
MI*00071781901~N3*1035 UTOPIA~N4*SAN ANTONIO*TX*78223~NM1*PR*2*HUMANA HMO*****PI
*61101~N3*PO BOX 15610~N4*LEXINGTON*KY*405124610~LX*1~SV1*HC:99214:25*153*UN*1**
01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008KS~LX*2~SV1*HC:20553*92*UN*1**02*5
~DTP*472*D8*20131016~REF*6R*ZZZZZ008KT~LX*3~SV1*HC:J2795*50*UN*50**02*5~DTP*472*
D8*20131016~REF*6R*ZZZZZ008KU~LIN**N4*06332328821~CTP****1*UN~HL*3**20*1~NM1*85*
2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SA
N ANTONIO*TX*782583916~REF*EI*300780099~HL*4*3*22*0~SBR*P*18*******MB~NM1*IL*1*B
UCHNER*SARA*JANE***MI*465482410D~N3*131 INDIAN GRASS DR~N4*NEW BRAUNFELS*TX*7813
0~DMG*D8*19420227*F~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA
*170890108~REF*FY*85525287~CLM*2343*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20130716~REF
*EA*BUCSAR0001~HI*BK:3384*BF:7242*BF:7291*BF:7213*BF:V5869~NM1*DN*1*BACON*DONALD
*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X
~SBR*S*18*NONE******CI~OI***Y***Y~NM1*IL*1*BUCHNER*SARA*JANE***MI*3000521454~N3*
131 INDIAN GRASS DR~N4*NEW BRAUNFELS*TX*78130~NM1*PR*2*PHYSICIANS MUTUAL*****PI~
N3*PO BOX 2018~N4*OMAHA*NE*681032018~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*
472*D8*20131015~REF*6R*ZZZZZ008K1~LX*2~SV1*HC:G0434:QW*40*UN*1**05*1:5~DTP*472*D
8*20131015~REF*6R*ZZZZZ008K2~HL*5**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*168
9018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300
780099~HL*6*5*22*0~SBR*P*18*NONE******CI~NM1*IL*1*DOLLEY*FLORA****MI*910841619~N
3*7901 BROADWICK~N4*SAN ANTONIO*TX*78239~DMG*D8*19580826*F~NM1*PR*2*APWU HEALTH
PLAN (CIGNA)*****PI*62308~N3*CIGNA HEALTH PLAN P O BOX 188004~N4*CHATTANOOGA*TN*
37422~CLM*2355*153***11:B:1*Y*A*Y*Y~DTP*431*D8*20131011~REF*EA*DOLFLO0001~HI*BK:
3384*BF:7242*BF:72210*BF:7244~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*B
ACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**
01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008L1~HL*7**20*1~NM1*85*2*DONALD D BA
CON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*
782583916~REF*EI*300780099~HL*8*7*22*0~SBR*P*18*NONE******CI~NM1*IL*1*DOLLEY*FLO
RA****MI*910841619~N3*7901 BROADWICK~N4*SAN ANTONIO*TX*78239~DMG*D8*19580826*F~N
M1*PR*2*APWU HEALTH PLAN (CIGNA)*****PI*62308~N3*CIGNA HEALTH PLAN P O BOX 18800
4~N4*CHATTANOOGA*TN*37422~CLM*2383*709***11:B:1*Y*A*Y*Y~DTP*431*D8*20131011~REF*
EA*DOLFLO0001~HI*BK:3384*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*
1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99211:25*29*U
N*1**01*1:2~DTP*472*D8*20131016~REF*6R*ZZZZZ008N4~LX*2~SV1*HC:62369*180*UN*1**01
*1~DTP*472*D8*20131016~REF*6R*ZZZZZ008N5~LX*3~SV1*HC:J7799:KD::::FENTANYL 519271
01900 HYDROMORPHONE 51927100300*500*UN*1**01*1~DTP*472*D8*20131016~REF*6R*ZZZZZ0
08N6~NTE*ADD*NTE FENTANYL 286.00 MG/ML HYDROMORPHONE 70.30 MG/ML~LIN**N4*5192710
1900~CTP****1*UN~HL*9**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*5
25 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*10
*9*22*0~SBR*P*18*662956******CI~NM1*IL*1*RENTSCHLER*PATRICIA*A***MI*00249499202~
N3*28426 QUADRILLE LANE~N4*FAIR OAKS RANCH*TX*78015~DMG*D8*19531219*F~NM1*PR*2*H
UMANA PPO*****PI*61101~N3*P O BOX 14601~N4*LEXINGTON*KY*405124601~CLM*2389*1229*
**11:B:1*Y*A*Y*Y~DTP*431*D8*20130624~REF*EA*RENPAT0001~HI*BK:3384*BF:7242~NM1*DN
*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE
*PXC*174400000X~LX*1~SV1*HC:64635:LT*575*UN*1**02*2~DTP*472*D8*20131017~REF*6R*Z
ZZZZ008P2~LX*2~SV1*HC:J0702*4*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008P6~L

IN**N4*00517072001~CTP****1*UN~LX*3~SV1*HC:J3010*100*UN*100**02*2~DTP*472*D8*201
31017~REF*6R*ZZZZZ008P7~LIN**N4*00409909422~CTP****1*UN~LX*4~SV1*HC:64636:LT*237
*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008P9~LX*5~SV1*HC:J2250*3*UN*3**02*2
~DTP*472*D8*20131017~REF*6R*ZZZZZ008PC~LIN**N4*00409230517~CTP****1*UN~LX*6~SV1*
HC:J3490:::::PROPOFOL 10ML*300*UN*20**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008PD
~NTE*ADD*NTE PROPOFOL 200 MG/ML~LIN**N4*00409469930~CTP****10*UN~LX*7~SV1*HC:Q99
63*10*UN*10**09*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008PE~HL*11**20*1~NM1*85*2*DON
ALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANT
ONIO*TX*782583916~REF*EI*300780099~HL*12*11*22*0~SBR*P*18*083580201000001******C
I~NM1*IL*1*STRICKLAND*BEVERLY*M***MI*W184632910~N3*15031 OLD CREEK~N4*SAN ANTONI
O*TX*78217~DMG*D8*19610130*F~NM1*PR*2*AETNA INC*****PI*60054~N3*P.O. BOX 981106~
N4*EL PASO*TX*799981106~CLM*2381*1159***11:B:1*Y*A*Y*Y~REF*EA*STRBEV0001~HI*BK:3
384*BF:7242*BF:7241*BF:72885~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BA
CON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18***12****MB~OI***Y***
Y~NM1*IL*1*STRICKLAND*BEVERLY*M***MI*469841102A~N3*15031 OLD CREEK~N4*SAN ANTONI
O*TX*78217~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*17089010
8~REF*FY*85525287~LX*1~SV1*HC:99211:25*29*UN*1**01*1:2:3~DTP*472*D8*20131016~REF
*6R*ZZZZZ008MT~LX*2~SV1*HC:J7799:KD::::BACLOFEN NDC 51927200725*450*UN*1**01*1:4
~DTP*472*D8*20131016~REF*6R*ZZZZZ008MU~NTE*ADD*NTE BACLOFEN 16.50 MG/ML~LIN**N4*
51927200725~CTP****1*UN~LX*3~SV1*HC:62369*180*UN*1**01*1~DTP*472*D8*20131016~REF
*6R*ZZZZZ008MV~LX*4~SV1*HC:J7799:KD::::FENTANYL 51927101900 HYDROMORPHONE 519271
00300*500*UN*1**01*1:2~DTP*472*D8*20131016~REF*6R*ZZZZZ008MZ~NTE*ADD*NTE FENTNAY
L 198.00 MG/ML HYDROMORPHONE 163.90 MG/ML~LIN**N4*51927101900~CTP****1*UN~HL*13*
*20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SU
ITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*14*13*22*0~SBR*P*18*0835
80201000001******CI~NM1*IL*1*STRICKLAND*BEVERLY*M***MI*W184632910~N3*15031 OLD C
REEK~N4*SAN ANTONIO*TX*78217~DMG*D8*19610130*F~NM1*PR*2*AETNA INC*****PI*60054~N
3*P.O. BOX 981106~N4*EL PASO*TX*799981106~CLM*2373*193***11:B:1*Y*A*Y*Y~DTP*431*
D8*20130814~REF*EA*STRBEV0001~HI*BK:3384*BF:7242*BF:7241*BF:7820*BF:7295*BF:V586
9~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*197250228
4~PRV*PE*PXC*174400000X~SBR*S*18***12****MB~OI***Y***Y~NM1*IL*1*STRICKLAND*BEVER
LY*M***MI*469841102A~N3*15031 OLD CREEK~N4*SAN ANTONIO*TX*78217~NM1*PR*2*MEDICAR
E*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~LX*1~SV1*
HC:99214:25*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008M8~LX*2~SV1*
HC:80104*40*UN*1**05*1:6~DTP*472*D8*20131016~REF*6R*ZZZZZ008M9~HL*15**20*1~NM1*8
5*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*
SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*16*15*22*0~SBR*P*18*NONE******CI~NM
1*IL*1*WUNSH*BERNARD****MI*H04185949~N3*5922 LAKECREST~N4*SAN ANTONIO*TX*78222~D
MG*D8*19611215*M~NM1*PR*2*HUMANA HMO GOLD PLUS*****PI*61101~N3*P O BOX 14601~N4*
LEXINGTON*KY*405124601~CLM*2348*61***21:B:1*Y*A*Y*Y~DTP*431*D8*20130704~DTP*435*
D8*20131015~DTP*096*D8*20131015~REF*9F*059332796~REF*G1*059332796~REF*EA*WUNBER0
001~HI*BK:3384*BF:7242*BF:7820~NM1*DN*1*VINYARD*PATRICK*G***XX*1598831281~NM1*82
*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~NM1*77*2*METHODIST STONE
OAK MEDICAL RECORDS*****XX*1659525236~N3*1339 E SONTERRA BLVD~N4*SAN ANTONIO*TX
*782583916~SBR*S*18*NONE******MC~OI***Y***Y~NM1*IL*1*WUNSH*BERNARD****MI*5178513
62~N3*5922 LAKECREST~N4*SAN ANTONIO*TX*78222~REF*SY*456359669~NM1*PR*2*MEDICAID*
****PI~N3*P O BOX 200555~N4*AUSTIN*TX*78720~LX*1~SV1*HC:62367*61*UN*1**02*1~DTP
*472*D8*20131015~REF*6R*ZZZZZ008KN~HL*17**20*1~NM1*85*2*DONALD D BACON MD PA****
*XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF
*EI*300780099~HL*18*17*22*0~SBR*P*18*******MB~NM1*IL*1*SNOOK*MARILYN****MI*45392
8797A~N3*9022 GILL BRIDGE~N4*SAN ANTONIO*TX*78254~DMG*D8*19500727*F~NM1*PR*2*MED
ICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2
378*1159***11:B:1*Y*A*Y*Y~DTP*431*D8*20130618~REF*EA*SNOMAR0001~HI*BK:3384*BF:72
41*BF:72885~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX
*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*NONE******CH~OI***Y***Y~NM1*IL*1*SNOO
K*MARILYN****MI*176349692~N3*9022 GILL BRIDGE~N4*SAN ANTONIO*TX*78254~NM1*PR*2*T
RICARE FOR LIFE*****PI*TDDIR~N3*P O BOX 7890~N4*MADISON*WI*537077890~LX*1~SV1*HC
:99211:25*29*UN*1**01*1:2~DTP*472*D8*20131016~REF*6R*ZZZZZ008MI~LX*2~SV1*HC:6236
9*180*UN*1**01*1:2:3~DTP*472*D8*20131016~REF*6R*ZZZZZ008MJ~LX*3~SV1*HC:J7799:KD:
:::BACLOFEN NDC 51927200725*450*UN*1**01*1:3~DTP*472*D8*20131016~REF*6R*ZZZZZ008

MK~NTE*ADD*NTE BACLOFEN 17.60 MG/ML~LIN**N4*51927200725~CTP****1*UN~LX*4~SV1*HC:

J7799:KD::::FENTANYL 51927101900 HYDROMORPHONE 51927100300*500*UN*1**01*1:2~DTP*
472*D8*20131016~REF*6R*ZZZZZ008ML~NTE*ADD*NTE HYDROMORPHONE 31.53 MG/ML FENTANYL
165.00 MG/ML~LIN**N4*51927101900~CTP****1*UN~HL*19**20*1~NM1*85*2*DONALD D BACO
N MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*78
2583916~REF*EI*300780099~HL*20*19*22*0~SBR*P*18*******MB~NM1*IL*1*MANCIAS*ANNA*M
***MI*462886467A~N3*116 ROUTT PL~N4*ODEM*TX*78370~DMG*D8*19500311*F~NM1*PR*2*MED
ICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2
382*1109***11:B:1*Y*A*Y*Y~DTP*431*D8*20130819~REF*X4*45D2058148~REF*EA*MACANN000
1~HI*BK:78096*BF:72885~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DO
NALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*NONE******MC~OI***Y***Y~NM
1*IL*1*MANCIAS*ANNA*M***MI*517796028~N3*116 ROUTT PL~N4*ODEM*TX*78370~NM1*PR*2*M
EDICAID*****PI~N3*P O BOX 200555~N4*AUSTIN*TX*78720~LX*1~SV1*HC:99211:25*29*UN*
1**01*1:2~DTP*472*D8*20131016~REF*6R*ZZZZZ008N0~LX*2~SV1*HC:62369*180*UN*1**01*1
~DTP*472*D8*20131016~REF*6R*ZZZZZ008N1~LX*3~SV1*HC:J7799:KD::::BACLOFEN NDC 5192
7200725*450*UN*1**01*1:2~DTP*472*D8*20131016~REF*6R*ZZZZZ008N2~NTE*ADD*NTE BACLO
FEN 75090 MG/ML~LIN**N4*51927200725~CTP****1*UN~LX*4~SV1*HC:J7799:KD::::MORPHINE
NDC 51927100000*450*UN*1**01*1~DTP*472*D8*20131016~REF*6R*ZZZZZ008N3~NTE*ADD*NT
E MORPHINE 46.32 MG/ML~LIN**N4*05192710000~CTP****1*UN~HL*21**20*1~NM1*85*2*DONA
LD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTO
NIO*TX*782583916~REF*EI*300780099~HL*22*21*22*0~SBR*P*18*******MB~NM1*IL*1*MANCI
AS*ANNA*M***MI*462886467A~N3*116 ROUTT PL~N4*ODEM*TX*78370~DMG*D8*19500311*F~NM1
*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525
287~CLM*2347*1520***11:B:1*Y*A*Y*Y~DTP*431*D8*20130819~REF*X4*45D2058148~REF*EA*
MACANN0001~HI*BK:78096*BF:72885*BF:33383*BF:33382*BF:34671~NM1*DN*1*BACON*DONALD
*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X
~SBR*S*18*NONE******MC~OI***Y***Y~NM1*IL*1*MANCIAS*ANNA*M***MI*517796028~N3*116
ROUTT PL~N4*ODEM*TX*78370~NM1*PR*2*MEDICAID*****PI~N3*P O BOX 200555~N4*AUSTIN*
TX*78720~LX*1~SV1*HC:99214:25*153*UN*1**01*1:2:3:4~DTP*472*D8*20131015~REF*6R*ZZ
ZZZ008KD~LX*2~SV1*HC:64400:50*708*UN*4**02*1:5~DTP*472*D8*20131015~REF*6R*ZZZZZ0
08KE~LX*3~SV1*HC:J2795*99*UN*99**02*1:5~DTP*472*D8*20131015~REF*6R*ZZZZZ008KH~LI
N**N4*06332328821~CTP****1*UN~LX*4~SV1*HC:64405:59*146*UN*1**02*1:5~DTP*472*D8*2
0131015~REF*6R*ZZZZZ008KI~LX*5~SV1*HC:64450:50:59*115*UN*1**02*1:5~DTP*472*D8*20
131015~REF*6R*ZZZZZ008KJ~LX*6~SV1*HC:64418:50:59*205*UN*1**02*1:5~DTP*472*D8*201
31015~REF*6R*ZZZZZ008KK~LX*7~SV1*HC:20553*92*UN*1**02*1:5~DTP*472*D8*20131015~RE
F*6R*ZZZZZ008KL~LX*8~SV1*HC:J1100*2*UN*2**02*1:5~DTP*472*D8*20131015~REF*6R*ZZZZ
Z008KM~HL*23**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CE
NTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*24*23*22*0~
SBR*P*18*070299503100011******CI~NM1*IL*1*SIEGEL*DAVID****MI*W168548272~N3*3319
OLD FORGE DR~N4*SAN ANTONIO*TX*78230~DMG*D8*19450612*M~NM1*PR*2*AETNA*****PI*600
54~N3*P O BOX 14079~N4*LEXINGTON*KY*405124079~CLM*2374*193***11:B:1*Y*A*Y*Y~DTP*
431*D8*20130724~REF*EA*SIEDAV0001~HI*BK:3384*BF:7242*BF:7231*BF:7244*BF:V5869~NM
1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PR
V*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~R
EF*6R*ZZZZZ008MA~LX*2~SV1*HC:80104*40*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZ
ZZZ008MB~HL*25**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK
CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*26*25*22*
0~SBR*P*18*NONE******CI~NM1*IL*1*FOREHAND*BRIAN****MI*H02325134~N3*25550 BOERNE
STAGE RD 70~N4*SAN ANTONIO*TX*78255~DMG*D8*19640622*M~NM1*PR*2*HUMANA HMO GOLD P
LUS*****PI*61101~N3*P O BOX 14601~N4*LEXINGTON*KY*405124601~CLM*2385*1407***11:B
:1*Y*A*Y*Y~DTP*431*D8*20130924~REF*EA*FORBRI0001~HI*BK:33821*BF:7242~NM1*DN*1*BA
CON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*
174400000X~SBR*S*18*NONE******MC~OI***Y***Y~NM1*IL*1*FOREHAND*BRIAN****MI*509963
895~N3*25550 BOERNE STAGE RD 70~N4*SAN ANTONIO*TX*78255~REF*SY*451471549~NM1*PR*
2*MEDICAID*****PI~N3*P O BOX 200555~N4*AUSTIN*TX*78720~LX*1~SV1*HC:64635:RT*575
*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NN~LX*2~SV1*HC:J0702*8*UN*2**02*2
~DTP*472*D8*20131017~REF*6R*ZZZZZ008NR~LIN**N4*00517072001~CTP****1*UN~LX*3~SV1*
HC:J2250*20*UN*4**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NS~LIN**N4*00409258705
~CTP****1*UN~LX*4~SV1*HC:J3010*200*UN*200**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ
008NT~LIN**N4*00409909422~CTP****1*UN~LX*5~SV1*HC:64636:RT*474*UN*2**02*2~DTP*47

2*D8*20131017~REF*6R*ZZZZZ008NV~LX*6~SV1*HC:Q9963*10*UN*10**09*2~DTP*472*D8*2013
1017~REF*6R*ZZZZZ008NY~LX*7~SV1*HC:J3490:::::PROPOFOL 10ML*120*UN*8**02*2~DTP*47
2*D8*20131017~REF*6R*ZZZZZ008NZ~NTE*ADD*NTR PROPOFOL 80 MG/ML~LIN**N4*0040946993
0~CTP****10*UN~HL*27**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*52
5 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*28*
27*22*0~SBR*P*18*174010M007******BL~NM1*IL*1*CHAMBERLAIN*REBECCA****MI*FXF833A78
694~N3*1624 WHISPERING WATER~N4*SPRING BRANCH*TX*78070~DMG*D8*19520226*F~NM1*PR*
2*BLUE CROSS BLUE SHIELD*****PI*00900~N3*P O BOX 660044~N4*DALLAS*TX*75266~CLM*2
336*1170***11:B:1*Y*A*Y*Y~DTP*431*D8*20130702~REF*EA*CHAREB0001~HI*BK:3384*BF:72
42~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*19725022
84~PRV*PE*PXC*174400000X~SBR*S*18*NONE******CH~OI***Y***Y~NM1*IL*1*CHAMBERLAIN*R
EBECCA****MI*547644913~N3*1624 WHISPERING WATER~N4*SPRING BRANCH*TX*78070~REF*SY
*462786858~NM1*PR*2*TRICARE SOUTH*****PI*61125~N3*PO BOX 7031~N4*CAMDEN*SC*29020
~LX*1~SV1*HC:64483:RT*375*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HD~LX*2~
SV1*HC:J2795*200*UN*200**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HH~LIN**N4*0633
2328821~CTP****1*UN~LX*3~SV1*HC:J3010*100*UN*100**02*2~DTP*472*D8*20131015~REF*6
R*ZZZZZ008HI~LIN**N4*00409909422~CTP****1*UN~LX*4~SV1*HC:Q9962*10*UN*10**09*2~DT
P*472*D8*20131015~REF*6R*ZZZZZ008HL~LIN**N4*00407141361~CTP****1*UN~LX*5~SV1*HC:
J1885*30*UN*2**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HM~LX*6~SV1*HC:J2405*8*UN
*4**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HN~LIN**N4*06277802801~CTP****1*UN~L
X*7~SV1*HC:64484:RT*300*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HO~LX*8~SV
1*HC:J3301:::::INJECTION, TRIAMCINOLONE ACETONIDE, PER 10 MG*12*UN*3**01*2~DTP*4
72*D8*20131015~REF*6R*ZZZZZ008HR~LIN**N4*00003029328~CTP****10*UN~LX*9~SV1*HC:J3
490:::::PROPOFOL 10ML*135*UN*9**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HS~NTE*A
DD*NTE PROPOFOL 90 MG/ML~LIN**N4*00409469930~CTP****10*UN~HL*29**20*1~NM1*85*2*D
ONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN A
NTONIO*TX*782583916~REF*EI*300780099~HL*30*29*22*0~SBR*P*18*085000******BL~NM1*I
L*1*RHODEN*JODY*B***MI*ISD849657068~N3*1621 SOUTH ST~N4*KERRVILLE*TX*780285534~D
MG*D8*19501026*M~NM1*PR*2*BLUE CROSS BLUE SHIELD*****PI*00900~N3*P O BOX 660044~
N4*DALLAS*TX*75266~CLM*2346*153***11:B:1*Y*A*Y*Y~DTP*431*D8*20130708~REF*EA*RHOJ
UD0001~HI*BK:3384*BF:7231*BF:7242*BF:138~NM1*DN*1*BACON*DONALD*D***XX*1972502284
~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214
*153*UN*1**01*1:2:3:4~DTP*472*D8*20131015~REF*6R*ZZZZZ008KC~HL*31**20*1~NM1*85*2
*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN
ANTONIO*TX*782583916~REF*EI*300780099~HL*32*31*22*0~SBR*P*18*******MB~NM1*IL*1*
COVINGTON*MARY*T***MI*463927436A~N3*426 SUMMIT RIDGE N~N4*POINT VENTURE*TX*78645
~DMG*D8*19510315*F~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*
170890108~REF*FY*85525287~CLM*2360*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20131011~REF*
X4*45D2058148~REF*EA*COVMAR0001~HI*BK:3384*BF:7242*BF:7231*BF:78096*BF:7213*BF:V
5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*197250
2284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*201
31016~REF*6R*ZZZZZ008LF~LX*2~SV1*HC:G0434:QW*40*UN*1**05*1:6~DTP*472*D8*20131016
~REF*6R*ZZZZZ008LG~HL*33**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N
3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL
*34*33*22*0~SBR*P*18*******MB~NM1*IL*1*BURNS*BRADLEY****MI*452150251A~N3*2707 FM
1346~N4*LA VERNIA*TX*78121~DMG*D8*19571210*M~NM1*PR*2*MEDICARE*****PI*00156~N3*
POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2369*243***11:B:1*Y*A*Y
*Y~DTP*431*D8*20131010~REF*EA*BURBRA0001~HI*BK:33828*BF:7242*BF:7295*BF:72283*BF
:71941*BF:9538*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*D
ONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2
:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008M0~LX*2~SV1*HC:97535:59*50*UN*1**I*6:5:4
:3~DTP*472*D8*20131016~REF*6R*ZZZZZ008M1~LX*3~SV1*HC:G0434:QW*40*UN*1**05*1:7~DT
P*472*D8*20131016~REF*6R*ZZZZZ008M2~HL*35**20*1~NM1*85*2*DONALD D BACON MD PA***
**XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~RE
F*EI*300780099~HL*36*35*22*0~SBR*P*18*603087******CI~NM1*IL*1*KENNEY*RAYMOND****
MI*733539502~N3*2410 BLUE QUAIL~N4*SAN ANTONIO*TX*78232~DMG*D8*19490621*M~NM1*PR
*2*UNITED HEALTH CARE PACIFICARE NETWORK*****PI*87726~N3*P O BOX 30975~N4*SALT L
AKE CITY*UT*841300975~CLM*2370*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20130808~REF*EA*K
ENRAY0001~HI*BK:3384*BF:7295*BF:7231*BF:7242*BF:V5869~NM1*DN*1*BACON*DONALD*D***
XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1

~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008M3~LX*2~SV
1*HC:80104*40*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ008M4~HL*37**20*1~NM1
*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N
4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*38*37*22*0~SBR*P*18*553121******C
I~NM1*IL*1*WEBB*CODY****MI*700509596~N3*7830 E EVANS RD~N4*SAN ANTONIO*TX*782662
825~DMG*D8*19831223*M~NM1*PR*2*HUMANA PPO*****PI*61101~N3*P O BOX 14601~N4*LEXIN
GTON*KY*405124601~CLM*2337*1718***11:B:1*Y*A*Y*Y~DTP*431*D8*20130818~REF*EA*WEBC
OD0001~HI*BK:33828*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACO
N*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:64493:50*257*UN*1**
02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HT~LX*2~SV1*HC:J2250*5*UN*1**02*2~DTP*47
2*D8*20131015~REF*6R*ZZZZZ008HX~LIN**N4*00409258705~CTP****1*UN~LX*3~SV1*HC:J301
0*100*UN*100**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008HY~LIN**N4*00409909422~CTP
****1*UN~LX*4~SV1*HC:Q9962*10*UN*10**09*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008I1~
LIN**N4*00407141361~CTP****1*UN~LX*5~SV1*HC:J1885*30*UN*2**02*2~DTP*472*D8*20131
015~REF*6R*ZZZZZ008I2~LX*6~SV1*HC:J0690*2*UN*2**02*2~DTP*472*D8*20131015~REF*6R*
ZZZZZ008I3~LX*7~SV1*HC:64494:50*127*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ0
08I4~LX*8~SV1*HC:64495:50*384*UN*3**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008I5~L
X*9~SV1*HC:64450*115*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008I7~LX*10~SV1*
HC:J0690*1*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008I9~LX*11~SV1*HC:64640:5
0:59*195*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IA~LX*12~SV1*HC:64640:51:
59*195*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IB~LX*13~SV1*HC:J0702*12*UN
*12**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IC~LIN**N4*00517072001~CTP****1*UN~
LX*14~SV1*HC:J3490:::::PROPOFOL 10ML*285*UN*19**02*2~DTP*472*D8*20131015~REF*6R*
ZZZZZ008ID~NTE*ADD*NTE PROPFOL 190 MG/ML~LIN**N4*00409469930~CTP****10*UN~HL*39*
*20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SU
ITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*40*39*22*0~SBR*P*18*0717
78******BL~NM1*IL*1*MORMINO*JANET*S***MI*UTS0GT2AK172~N3*12802 VIDORRA CIRCLE~N4
*SAN ANTONIO*TX*78216~DMG*D8*19570201*F~NM1*PR*2*BLUE CROSS BLUE SHIELD*****PI*0
0900~N3*P O BOX 660044~N4*DALLAS*TX*75266~CLM*2363*193***11:B:1*Y*A*Y*Y~DTP*431*
D8*20130716~REF*EA*MORJAN0001~HI*BK:3384*BF:7242*BF:7295*BF:7244*BF:V5869~NM1*DN
*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE
*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6
R*ZZZZZ008LO~LX*2~SV1*HC:80104*40*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ0
08LP~HL*41**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENT
RE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*42*41*22*0~SB
R*P*18*NONE******CH~NM1*IL*1*DUNLAP*VANDA****MI*450154807~N3*1218 CROSSING OAKS~
N4*SAN ANTONIO*TX*78253~DMG*D8*19661208*F~NM1*PR*2*TRICARE SOUTH*****PI*61125~N3
*PO BOX 7031~N4*CAMDEN*SC*29020~CLM*2384*1025***11:B:1*Y*A*Y*Y~DTP*431*D8*201308
20~REF*EA*DUNVAN0001~HI*BK:3384*BF:7231~NM1*DN*1*BACON*DONALD*D***XX*1972502284~
NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:64490:
50*285*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008N7~LX*2~SV1*HC:J0702*8*UN*2
**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NB~LIN**N4*00517072001~CTP****1*UN~LX*
3~SV1*HC:J3010*100*UN*100**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NC~LIN**N4*00
409909422~CTP****1*UN~LX*4~SV1*HC:J2795*25*UN*25**02*2~DTP*472*D8*20131017~REF*6
R*ZZZZZ008ND~LIN**N4*06332328821~CTP****1*UN~LX*5~SV1*HC:Q9962*10*UN*10**09*2~DT
P*472*D8*20131017~REF*6R*ZZZZZ008NF~LIN**N4*00407141361~CTP****1*UN~LX*6~SV1*HC:
64491:50*139*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NG~LX*7~SV1*HC:64405:
50:59*146*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NH~LX*8~SV1*HC:64450:50:
59*115*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NI~LX*9~SV1*HC:J3490:::::PR
OPOFOL 10ML*195*UN*13**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NL~NTE*ADD*NTE PR
OPOFOL 130 MG/ML~LIN**N4*00409469930~CTP****10*UN~LX*10~SV1*HC:J2250*2*UN*2**02*
2~DTP*472*D8*20131017~REF*6R*ZZZZZ008NM~LIN**N4*00409230517~CTP****1*UN~HL*43**2
0*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUIT
E 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*44*43*22*0~SBR*P*18*******
MB~NM1*IL*1*BANKER*DEBORAH*KAY***MI*463865606A~N3*3401 OAK FOREST DRIVE~N4*LEAND
ER*TX*78645~DMG*D8*19491003*F~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CA
MP HILL*PA*170890108~REF*FY*85525287~CLM*2358*634***11:B:1*Y*A*Y*Y~REF*EA*BANDEB
0001~HI*BK:3384*BF:7242*BF:7231*BF:78096*BF:71516*BF:V5869~NM1*DN*1*BACON*DONALD
*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X
~SBR*S*18*NONE******MC~OI***Y***Y~NM1*IL*1*BANKER*DEBORAH*KAY***MI*526472952~N3*

3401 OAK FOREST DRIVE~N4*LEANDER*TX*78645~NM1*PR*2*MEDICAID*****PI~N3*P O BOX 2

00555~N4*AUSTIN*TX*78720~LX*1~SV1*HC:99214:25*153*UN*1**01*1:2:3:4~DTP*472*D8*20
131016~REF*6R*ZZZZZ008L5~LX*2~SV1*HC:20610:RT*86*UN*1**01*5~DTP*472*D8*20131016~
REF*6R*ZZZZZ008L6~LX*3~SV1*HC:J2795*50*UN*50**02*5~DTP*472*D8*20131016~REF*6R*ZZ
ZZZ008L9~LIN**N4*06332328821~CTP****1*UN~LX*4~SV1*HC:76942:59*289*UN*1**04*5~DTP
*472*D8*20131016~REF*6R*ZZZZZ008LB~LX*5~SV1*HC:J3301:::::INJECTION, TRIAMCINOLON
E ACETONIDE, PER 10 MG*16*UN*4**01*5~DTP*472*D8*20131016~REF*6R*ZZZZZ008LC~LIN**
N4*00003029328~CTP****10*UN~LX*6~SV1*HC:G0434:QW*40*UN*1**05*1:6~DTP*472*D8*2013
1016~REF*6R*ZZZZZ008LD~HL*45**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*16890180
79~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*30078009
9~HL*46*45*22*0~SBR*P*18*189416******CI~NM1*IL*1*BECK*BRAD****MI*977753179~N3*12
315 JONES MALTSBERGER #608~N4*SAN ANTONIO*TX*78247~DMG*D8*19830404*M~NM1*PR*2*UN
ITED HEALTH CARE*****PI*87726~N3*P O BOX 30555~N4*SALT LAKE CITY*UT*841300555~CL
M*2364*153***11:B:1*Y*A*Y*Y~DTP*431*D8*20130819~REF*EA*BECBRA0001~HI*BK:33821*BF
:7242*BF:7213*BF:72210*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1
*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1
**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008LQ~HL*47**20*1~NM1*85*2*DONALD D
BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*
TX*782583916~REF*EI*300780099~HL*48*47*22*0~SBR*P*18*******MB~NM1*IL*1*CALHOUN*J
EFFERY****MI*279547177A~N3*323 RITTIMAN RD~N4*SPRING BRANCH*TX*78070~DMG*D8*1955
0701*M~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~RE
F*FY*85525287~CLM*2367*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20130711~REF*X4*45D205814
8~REF*EA*CALJEF0001~HI*BK:3384*BF:78096*BF:7295*BF:7242*BF:V5869~NM1*DN*1*BACON*
DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*1744
00000X~SBR*S*18*NONE******CH~OI***Y***Y~NM1*IL*1*CALHOUN*JEFFERY****MI*279547177
~N3*323 RITTIMAN RD~N4*SPRING BRANCH*TX*78070~NM1*PR*2*TRICARE FOR LIFE*****PI*T
DDIR~N3*P O BOX 7890~N4*MADISON*WI*537077890~LX*1~SV1*HC:99214*153*UN*1**01*1:2:
3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008LW~LX*2~SV1*HC:G0434:QW*40*UN*1**05*1:5~D
TP*472*D8*20131016~REF*6R*ZZZZZ008LX~HL*49**20*1~NM1*85*2*DONALD D BACON MD PA**
***XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~R
EF*EI*300780099~HL*50*49*22*0~SBR*P*18*017118******BL~NM1*IL*1*CALLINS*GEORGE***
*MI*ZGR900086848~N3*11306 ANCIENT COACH~N4*SAN ANTONIO*TX*78213~DMG*D8*19540422*
M~NM1*PR*2*BLUE CROSS BLUE SHIELD*****PI*00900~N3*P O BOX 660044~N4*DALLAS*TX*75
266~CLM*2371*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20131010~REF*EA*CALGEO0001~HI*BK:33
84*BF:7242*BF:7231*BF:78096*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1
*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153
*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008M5~LX*2~SV1*HC:80104*40*UN*
1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ008M6~HL*51**20*1~NM1*85*2*DONALD D BA
CON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*
782583916~REF*EI*300780099~HL*52*51*22*0~SBR*P*18*704812******CI~NM1*IL*1*REYNOL
DS*TABITHA****MI*915269643~N3*1935 BROKEN OAK #201~N4*SAN ANTONIO*TX*78232~DMG*D
8*19780529*F~NM1*PR*2*UNITED HEALTHCARE*****PI*87726~N3*PO BOX 740800~N4*ATLANTA
*GA*303740800~CLM*2339*916***11:B:1*Y*A*Y*Y~DTP*431*D8*20130618~REF*EA*REYTAB000
1~HI*BK:33821*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DON
ALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:64483:RT*375*UN*1**02*2~
DTP*472*D8*20131015~REF*6R*ZZZZZ008IR~LX*2~SV1*HC:A4657*2*UN*2**09*2~DTP*472*D8*
20131015~REF*6R*ZZZZZ008IU~LX*3~SV1*HC:J1885*30*UN*2**02*2~DTP*472*D8*20131015~R
EF*6R*ZZZZZ008IV~LX*4~SV1*HC:J2250*5*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ
008IW~LIN**N4*00409258705~CTP****1*UN~LX*5~SV1*HC:J3010*100*UN*100**02*2~DTP*472
*D8*20131015~REF*6R*ZZZZZ008IX~LIN**N4*00409909422~CTP****1*UN~LX*6~SV1*HC:Q9962
*10*UN*10**09*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IZ~LIN**N4*00407141361~CTP***
*1*UN~LX*7~SV1*HC:64484:RT*300*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008J1~
LX*8~SV1*HC:J3301:::::INJECTION, TRIAMCINOLONE ACETONIDE, PER 10 MG*4*UN*1**01*2
~DTP*472*D8*20131015~REF*6R*ZZZZZ008J3~LIN**N4*00003029328~CTP****10*UN~LX*9~SV1
*HC:J3490:::::PROPOFOL 10ML*90*UN*6**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008J4~
NTE*ADD*NTE PROPOFOL 60 MG/ML~LIN**N4*00409469930~CTP****10*UN~HL*53**20*1~NM1*8
5*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*
SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*54*53*22*0~SBR*P*18*******MB~NM1*IL
*1*CHACON*JANA*S***MI*452066843A~N3*131 INDIAN GRASS DR~N4*NEW BRAUNFELS*TX*7813
0~DMG*D8*19591214*F~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA

*170890108~REF*FY*85525287~CLM*2344*287***11:B:1*Y*A*Y*Y~REF*EA*CHAJAN0001~HI*BK
:33821*BF:7242*BF:7295*BF:7231*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~
NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*
153*UN*1**01*1:2:3:4~DTP*472*D8*20131015~REF*6R*ZZZZZ008K3~LX*2~SV1*HC:G0434:QW*
40*UN*1**05*1:5~DTP*472*D8*20131015~REF*6R*ZZZZZ008K4~LX*3~SV1*HC:20610*86*UN*1*
*01*3~DTP*472*D8*20131015~REF*6R*ZZZZZ008K5~LX*4~SV1*HC:J3301:::::INJECTION, TRI
AMCINOLONE ACETONIDE, PER 10 MG*8*UN*2**01*3~DTP*472*D8*20131015~REF*6R*ZZZZZ008
K6~LIN**N4*00003029328~CTP****10*UN~HL*55**20*1~NM1*85*2*DONALD D BACON MD PA***
**XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~RE
F*EI*300780099~HL*56*55*22*0~SBR*P*18*******MB~NM1*IL*1*CHADWICK*NEIL****MI*3346
65184A~N3*12446 SIR WINSTON ST APT 404~N4*SAN ANTONIO*TX*78216~DMG*D8*19720425*M
~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*8
5525287~CLM*2387*1684***11:B:1*Y*A*Y*Y~DTP*431*D8*20130619~REF*EA*CHANEI0001~HI*
BK:33828*BF:7231~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D
***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*100400******CI~OI***Y***Y~NM1*IL
*1*CHADWICK*NEIL****MI*957713485~N3*12446 SIR WINSTON ST APT 404~N4*SAN ANTONIO*
TX*78216~NM1*PR*2*UNITED HEALTHCARE*****PI*87726~N3*PO BOX 740800~N4*ATLANTA*GA*
303740800~LX*1~SV1*HC:64633:50*586*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ00
8OD~LX*2~SV1*HC:J3010*100*UN*100**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008OG~LIN
**N4*00409909422~CTP****1*UN~LX*3~SV1*HC:Q9962*10*UN*10**09*2~DTP*472*D8*2013101
7~REF*6R*ZZZZZ008OI~LIN**N4*00407141361~CTP****1*UN~LX*4~SV1*HC:J0702*8*UN*2**02
*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008OJ~LIN**N4*00517072001~CTP****1*UN~LX*5~SV
1*HC:64634:50*528*UN*2**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008OK~LX*6~SV1*HC:J
2250*2*UN*2**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008ON~LIN**N4*00409230517~CTP*
***1*UN~LX*7~SV1*HC:J3490:::::PROPOFOL 10ML*450*UN*30**02*2~DTP*472*D8*20131017~
REF*6R*ZZZZZ008OO~NTE*ADD*NTE PROPOFOL 300 MG/ML~LIN**N4*00409469930~CTP****10*U
N~HL*57**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE
DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*58*57*22*0~SBR*P
*18*******MB~NM1*IL*1*RIESENECKER*FRANK*W***MI*466420667A~N3*239 TUXEDO~N4*SAN A
NTONIO*TX*78209~DMG*D8*19250121*M~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N
4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2386*1126***11:B:1*Y*A*Y*Y~DTP*431*
D8*20130903~REF*EA*RIEFRA0001~HI*BK:33828*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1
972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1
*HC:64483:50*375*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008O0~LX*2~SV1*HC:J3
010*50*UN*50**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008O4~LIN**N4*00409909422~CTP
****1*UN~LX*3~SV1*HC:Q9962*10*UN*10**09*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008O6~
LIN**N4*00407141361~CTP****1*UN~LX*4~SV1*HC:64484:LT*300*UN*1**02*2~DTP*472*D8*2
0131017~REF*6R*ZZZZZ008O7~LX*5~SV1*HC:64484:RT*300*UN*1**02*2~DTP*472*D8*2013101
7~REF*6R*ZZZZZ008O8~LX*6~SV1*HC:J2250*1*UN*1**02*2~DTP*472*D8*20131017~REF*6R*ZZ
ZZZ008OA~LIN**N4*00409230517~CTP****1*UN~LX*7~SV1*HC:J3490:::::PROPOFOL 10ML*90*
UN*6**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008OB~NTE*ADD*NTE PROPFOL 60 MG/ML~LI
N**N4*00409469930~CTP****10*UN~HL*59**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*
1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*
300780099~HL*60*59*22*0~SBR*P*18*47477201200005******CI~NM1*IL*1*LOGAN*BRITTANY*
***MI*W198390734~N3*2815 NORTH MAIN AVE~N4*GEORGETOWN*TX*78212~DMG*D8*19900112*F
~NM1*PR*2*AETNA INC*****PI*60054~N3*P.O. BOX 981106~N4*EL PASO*TX*799981106~CLM*
2377*153***11:B:1*Y*A*Y*Y~DTP*431*D8*20130619~REF*EA*LOGBRI0001~HI*BK:33821*BF:7
241*BF:80700*BF:7242*BF:7212~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BA
CON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**0
1*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008MH~HL*61**20*1~NM1*85*2*DONALD D BA
CON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*
782583916~REF*EI*300780099~HL*62*61*22*0~SBR*P*18*******MB~NM1*IL*1*WILLIAMS*SHA
RON*M***MI*467781893A~N3*100 SNOWBERRY~N4*CIBOLO*TX*78108~DMG*D8*19450815*F~NM1*
PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*855252
87~CLM*2341*295***11:B:1*Y*A*Y*Y~DTP*431*D8*20130708~REF*X4*45D2058148~REF*EA*WI
LSHA0001~HI*BK:33828*BF:7242*BF:7295*BF:72283~NM1*DN*1*BACON*DONALD*D***XX*19725
02284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*NON
E******CI~OI***Y***Y~NM1*IL*1*WILLIAMS*SHARON*M***MI*51528888~N3*100 SNOWBERRY~N
4*CIBOLO*TX*78108~NM1*PR*2*MUTUAL OF OMAHA*****PI~N3*MUTUAL OF OMAHA PLAZA~N4*OM
AHA*NE*68175~LX*1~SV1*HC:99214:25*153*UN*1**01*1:2:3:4~DTP*472*D8*20131015~REF*6

R*ZZZZZ008JR~LX*2~SV1*HC:20553:59*92*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ
008JS~LX*3~SV1*HC:J2795*50*UN*50**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008JU~LIN
**N4*06332328821~CTP****1*UN~HL*63**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*16
89018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*30
0780099~HL*64*63*22*0~SBR*P*18*R5768******CI~NM1*IL*1*MOHR*MICHAEL*W***MI*H59366
492~N3*24720 N FM 81~N4*HOBSON*TX*78117~DMG*D8*19640716*M~NM1*PR*2*HUMANA MEDICA
RE ADVANTAGE (PPO)*****PI*61101~N3*PO BOX 14678~N4*LEXINGTON*KY*405124678~CLM*23
61*320***11:B:1*Y*A*Y*Y~DTP*431*D8*20130813~REF*9F*2013082211500014~REF*EA*MOHMI
C0005~HI*BK:33821*BF:7242*BF:78096*BF:7244~NM1*82*1*BACON*DONALD*D***XX*19725022
84~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214:25*153*UN*1**01*1:2:3:4~DTP*472*D8*20
131016~REF*6R*ZZZZZ008LH~LX*2~SV1*HC:20553*92*UN*1**02*2~DTP*472*D8*20131016~REF
*6R*ZZZZZ008LI~LX*3~SV1*HC:J2795*75*UN*75**02*2~DTP*472*D8*20131016~REF*6R*ZZZZZ
008LK~LIN**N4*06332328821~CTP****1*UN~HL*65**20*1~NM1*85*2*DONALD D BACON MD PA*
****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~
REF*EI*300780099~HL*66*65*22*0~SBR*P*18*3309644******CI~NM1*IL*1*HUBER*PEGGY*L**
*MI*U0464057902~N3*8210 GLENN LARK~N4*SAN ANTONIO*TX*78239~DMG*D8*19600917*F~NM1
*PR*2*CIGNA*****PI*62308~N3*PO BOX 15050~N4*WILLMINGTON*DE*198505050~CLM*2365*19
3***11:B:1*Y*A*Y*Y~DTP*431*D8*20130723~REF*EA*HUBPEG0001~HI*BK:3384*BF:7242*BF:7
231*BF:72210*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DON
ALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3
:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008LR~LX*2~SV1*HC:80104*40*UN*1**05*1:5~DTP*4
72*D8*20131016~REF*6R*ZZZZZ008LT~HL*67**20*1~NM1*85*2*DONALD D BACON MD PA*****X
X*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*E
I*300780099~HL*68*67*22*0~SBR*P*18*8K9809******CI~NM1*IL*1*MCGEE*ANNETTE****MI*9
36658550~N3*230 IRON HORSE~N4*NEW BRAUNFELS*TX*78132~DMG*D8*19630125*F~NM1*PR*2*
UNITED HEALTHCARE*****PI*87726~N3*PO BOX 740800~N4*ATLANTA*GA*303740800~CLM*2388
*660***11:B:1*Y*A*Y*Y~DTP*431*D8*20130722~REF*EA*MCGANN0001~HI*BK:3384*BF:7220~N
M1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~P
RV*PE*PXC*174400000X~LX*1~SV1*HC:62310*355*UN*1**02*2~DTP*472*D8*20131017~REF*6R
*ZZZZZ008OP~LX*2~SV1*HC:J2250*10*UN*2**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008O
T~LIN**N4*00409258705~CTP****1*UN~LX*3~SV1*HC:J3010*100*UN*100**02*2~DTP*472*D8*
20131017~REF*6R*ZZZZZ008OU~LIN**N4*00409909422~CTP****1*UN~LX*4~SV1*HC:Q9962*10*
UN*10**09*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008OW~LIN**N4*00407141361~CTP****1*U
N~LX*5~SV1*HC:J0702*20*UN*5**02*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008OX~LIN**N4*
00517072001~CTP****1*UN~LX*6~SV1*HC:J3490:::::PROPOFOL 10ML*90*UN*6**02*2~DTP*47
2*D8*20131017~REF*6R*ZZZZZ008P1~NTE*ADD*NTE PROPFOL 60 MG/ML~LIN**N4*00409469930
~CTP****10*UN~LX*7~SV1*HC:77003:26*75*UN*1**04*2~DTP*472*D8*20131017~REF*6R*ZZZZ
Z008PF~HL*69**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CE
NTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*70*69*22*0~
SBR*P*18*******MB~NM1*IL*1*LANDEN*MISTY*E***MI*455592499A~N3*902 KITTY HAWK ROAD
#170/201~N4*UNIVERSAL CITY*TX*78148~DMG*D8*19820207*F~NM1*PR*2*MEDICARE*****PI*
00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2362*153***11:
B:1*Y*A*Y*Y~DTP*431*D8*20130708~REF*X4*45D2058148~REF*EA*LANMIS0001~HI*BK:3384*B
F:7242*BF:78096*BF:78652*BF:20280*BF:7234~NM1*DN*1*BACON*DONALD*D***XX*197250228
4~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:9921
4*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008LL~HL*71**20*1~NM1*85*
2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SA
N ANTONIO*TX*782583916~REF*EI*300780099~HL*72*71*22*0~SBR*P*18*US35405410300010*
*****CI~NM1*IL*1*PERRY*CANDICE*A***MI*MEBCMC7T~N3*3505 ACKERMAN ROAD~N4*SAN ANTO
NIO*TX*78219~DMG*D8*19610903*F~NM1*PR*2*AETNA MEDICARE*****PI*60054~N3*PO BOX 98
1106~N4*EL PASO*TX*799981106~CLM*2359*153***11:B:1*Y*A*Y*Y~DTP*431*D8*20131011~R
EF*EA*PERCAN0001~HI*BK:3384*BF:7242*BF:7295*BF:7840*BF:7231~NM1*DN*1*BACON*DONAL
D*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000
X~LX*1~SV1*HC:99214:25*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008L
E~HL*73**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE
DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*74*73*22*0~SBR*P
*18*US35405410300010******CI~NM1*IL*1*PERRY*CANDICE*A***MI*MEBCMC7T~N3*3505 ACKE
RMAN ROAD~N4*SAN ANTONIO*TX*78219~DMG*D8*19610903*F~NM1*PR*2*AETNA MEDICARE*****
PI*60054~N3*PO BOX 981106~N4*EL PASO*TX*799981106~CLM*2380*1309***11:B:1*Y*A*Y*Y
~DTP*431*D8*20131011~REF*EA*PERCAN0001~HI*BK:3384*BF:7242*BF:7295*BF:7840~NM1*DN

*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE
*PXC*174400000X~LX*1~SV1*HC:99211:25*29*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF
*6R*ZZZZZ008MQ~LX*2~SV1*HC:62369*180*UN*1**01*1~DTP*472*D8*20131016~REF*6R*ZZZZZ
008MR~LX*3~SV1*HC:J7799:KD::::FENTANYL 51927101900 MORPHINE 5192710000 BUPIVIACI
NE 5192723*1100*UN*1**01*1:2~DTP*472*D8*20131016~REF*6R*ZZZZZ008MS~NTE*ADD*NTE F
ENTANTYL 1050.00 MG/ML MORPHINE 592.20 MG/ML BUPIVICIANE 592.20MG/ML~LIN**N4*519
27101900~CTP****1*UN~HL*75**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079
~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~
HL*76*75*22*0~SBR*P*18*******MB~NM1*IL*1*ROLLINS*KATHLEEN*L***MI*234886875A~N3*9
582 CANTURA CREST~N4*SAN ANTONIO*TX*78250~DMG*D8*19530913*F~NM1*PR*2*MEDICARE***
**PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2376*193*
**11:B:1*Y*A*Y*Y~DTP*431*D8*20130717~REF*X4*45D2058148~REF*EA*ROLKAT0001~HI*BK:3
384*BF:7295*BF:7231*BF:71945*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM
1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*15
3*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008MF~LX*2~SV1*HC:G0434:QW*40
*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ008MG~HL*77**20*1~NM1*85*2*DONALD
D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO
*TX*782583916~REF*EI*300780099~HL*78*77*22*0~SBR*P*18*******MB~NM1*IL*1*WOLF*CAR
LA****MI*457804539T~N3*20815 ENCINO PEBBLE~N4*SAN ANTONIO*TX*78259~DMG*D8*194708
19*F~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*
FY*85525287~CLM*2342*295***11:B:1*Y*A*Y*Y~DTP*431*D8*20130702~REF*X4*45D2058148~
REF*EA*WOLCAR0001~HI*BK:33828*BF:7231*BF:7242*BF:7210*BF:7291~NM1*DN*1*BACON*DON
ALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*1744000
00X~SBR*S*18*PLAN F******CI~OI***Y***Y~NM1*IL*1*WOLF*CARLA****MI*06749770912~N3*
20815 ENCINO PEBBLE~N4*SAN ANTONIO*TX*78259~NM1*PR*2*UNITEDHEALTHCARE*****PI*877
26~N3*PO BOX 740819~N4*ATLANTA*GA*303740819~LX*1~SV1*HC:99214:25*153*UN*1**01*1:
2:3:4~DTP*472*D8*20131015~REF*6R*ZZZZZ008JW~LX*2~SV1*HC:20553*92*UN*1**02*5~DTP*
472*D8*20131015~REF*6R*ZZZZZ008JX~LX*3~SV1*HC:J2795*50*UN*50**02*5~DTP*472*D8*20
131015~REF*6R*ZZZZZ008JZ~LIN**N4*06332328821~CTP****1*UN~HL*79**20*1~NM1*85*2*DO
NALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN AN
TONIO*TX*782583916~REF*EI*300780099~HL*80*79*22*0~SBR*P*18*******MB~NM1*IL*1*ELI
KER*ROMA*L***MI*452020416A~N3*P.O. BOX 63868~N4*PIPE CREEK*TX*78063~DMG*D8*19521
130*F~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF
*FY*85525287~CLM*2391*295***11:B:1*Y*A*Y*Y~DTP*431*D8*20130730~REF*X4*45D2058148
~REF*EA*ELIROM0001~HI*BK:3384*BF:7231*BF:7242*BF:7295*BF:7820~NM1*DN*1*BACON*DON
ALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*1744000
00X~SBR*S*01*NONE******CH~OI***Y***Y~NM1*IL*1*ELIKER*HADLEY*BRUCE***MI*454743651
~N3*950 MUSTANG XNG POB 63868~N4*PIPE CREEK*TX*78063~NM1*PR*2*TRICARE FOR LIFE**
***PI*TDDIR~N3*P O BOX 7890~N4*MADISON*WI*537077890~LX*1~SV1*HC:99214*153*UN*1**
01*1:2:5:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008PH~LX*2~SV1*HC:20553:59*92*UN*1**0
2*1:3~DTP*472*D8*20131017~REF*6R*ZZZZZ008PI~LX*3~SV1*HC:J2795*50*UN*50**02*1:3~D
TP*472*D8*20131017~REF*6R*ZZZZZ008PK~LIN**N4*06332328821~CTP****1*UN~HL*81**20*1
~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 1
40~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*82*81*22*0~SBR*P*18*P5347009*
*****CI~NM1*IL*1*FERRARI*JANE*F***MI*H40246210~N3*101 RIO BRAVO~N4*SAN ANTONIO*T
X*78232~DMG*D8*19590429*F~NM1*PR*2*HUMANA PPO*****PI*61101~N3*P O BOX 14601~N4*L
EXINGTON*KY*405124601~CLM*2368*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20130627~REF*EA*F
ERJAN0001~HI*BK:3384*BF:7231*BF:7220*BF:7234*BF:V5869~NM1*DN*1*BACON*DONALD*D***
XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1
~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008LY~LX*2~SV
1*HC:80104*40*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ008LZ~HL*83**20*1~NM1
*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N
4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*84*83*22*0~SBR*P*18*******MB~NM1*
IL*1*LEE*EDGAR*B***MI*251742056A~N3*1135 GARDENIA~N4*NEW BRAUNFELS*TX*78130~DMG*
D8*19460216*M~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAMP HILL*PA*17089
0108~REF*FY*85525287~CLM*2340*1380***11:B:1*Y*A*Y*Y~REF*X4*45D2058148~REF*EA*LEE
EDG0001~HI*BK:3384*BF:7242*BF:71511*BF:25000~NM1*DN*1*BACON*DONALD*D***XX*197250
2284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*8959
8030100******CI~OI***Y***Y~NM1*IL*1*LEE*EDGAR*B***MI*W104004619~N3*1135 GARDENIA
~N4*NEW BRAUNFELS*TX*78130~NM1*PR*2*AETNA INC*****PI*60054~N3*P.O. BOX 981106~N4

*EL PASO*TX*799981106~LX*1~SV1*HC:64635:50*575*UN*1**02*2~DTP*472*D8*20131015~RE
F*6R*ZZZZZ008J5~LX*2~SV1*HC:J2250*5*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ0
08J9~LIN**N4*00409258705~CTP****1*UN~LX*3~SV1*HC:J3010*150*UN*150**02*2~DTP*472*
D8*20131015~REF*6R*ZZZZZ008JA~LIN**N4*00409909422~CTP****1*UN~LX*4~SV1*HC:Q9962*
10*UN*10**09*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008JD~LIN**N4*00407141361~CTP****
1*UN~LX*5~SV1*HC:J2795*50*UN*50**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008JE~LIN*
*N4*06332328821~CTP****1*UN~LX*6~SV1*HC:J1885*30*UN*2**02*2~DTP*472*D8*20131015~
REF*6R*ZZZZZ008JG~LX*7~SV1*HC:J2405*8*UN*4**02*2~DTP*472*D8*20131015~REF*6R*ZZZZ
Z008JH~LIN**N4*06277802801~CTP****1*UN~LX*8~SV1*HC:64636:50*237*UN*1**02*2~DTP*4
72*D8*20131015~REF*6R*ZZZZZ008JI~LX*9~SV1*HC:20610:50:59*86*UN*1**01*3~DTP*472*D
8*20131015~REF*6R*ZZZZZ008JM~LX*10~SV1*HC:J0702*12*UN*12**02*2~DTP*472*D8*201310
15~REF*6R*ZZZZZ008JN~LIN**N4*00517072001~CTP****1*UN~LX*11~SV1*HC:J3301:::::INJE
CTION, TRIAMCINOLONE ACETONIDE, PER 10 MG*32*UN*8**01*3~DTP*472*D8*20131015~REF*
6R*ZZZZZ008JO~LIN**N4*00003029328~CTP****10*UN~LX*12~SV1*HC:J3490:::::PROPOFOL 1
0ML*180*UN*12**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008JP~NTE*ADD*NTE PROPFOL 12
0 MG/ML~LIN**N4*00409469930~CTP****10*UN~LX*13~SV1*HC:82962*5*UN*1**05*4~DTP*472
*D8*20131015~REF*6R*ZZZZZ008JQ~HL*85**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*
1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*
300780099~HL*86*85*22*0~SBR*P*18*******MB~NM1*IL*1*OSBORNE*ROY****MI*467327877A~
N3*211 SHADYWOOD~N4*SAN ANTONIO*TX*78216~DMG*D8*19221228*M~NM1*PR*2*MEDICARE****
*PI*00156~N3*POB 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2351*193**
*11:B:1*Y*A*Y*Y~DTP*431*D8*20130808~REF*X4*45D2058148~REF*EA*OSBROY0001~HI*BK:33
84*BF:7242*BF:7291*BF:71945*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1
*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*18*NONE******CI
~OI***Y***Y~NM1*IL*1*OSBORNE*ROY****MI*OSW017600~N3*211 SHADYWOOD~N4*SAN ANTONIO
*TX*78216~NM1*PR*2*STANDARD LIFE & ACCIDENT INS CO*****PI~N3*PO BOX 1800~N4*GALV
ESTON*TX*77553~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131015~REF*6R
*ZZZZZ008KQ~LX*2~SV1*HC:G0434:QW*40*UN*1**05*1:5~DTP*472*D8*20131015~REF*6R*ZZZZ
Z008KR~HL*87**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CE
NTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*88*87*22*0~
SBR*P*18*******MB~NM1*IL*1*MOORE*KERRY*M***MI*457666123A~N3*31109 SMITHSON VALLE
Y RD~N4*BULVERDE*TX*78163~DMG*D8*19411221*F~NM1*PR*2*MEDICARE*****PI*00156~N3*PO
B 890108~N4*CAMP HILL*PA*170890108~REF*FY*85525287~CLM*2349*153***11:B:1*Y*A*Y*Y
~DTP*431*D8*20130731~REF*X4*45D2058148~REF*EA*MOOKER0001~HI*BK:33828*BF:7242*BF:
7244~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*197250
2284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3~DTP*472*D8*20131
015~REF*6R*ZZZZZ008KO~HL*89**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*168901807
9~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099
~HL*90*89*22*1~SBR*P**NONE******CI~NM1*IL*2*US POSTAL SERVICE~NM1*PR*2*DEPT OF L
ABOR/OWCP*****PI*77044~N3*P O BOX 8300~N4*LONDON*KY*407428300~HL*91*90*23*0~PAT*
G8~NM1*QC*1*NICHOLS*WILLIAM~N3*987 MEADOW WAY~N4*CONVERSE*TX*78109~DMG*D8*195409
15*M~CLM*2392*739***11:B:1*Y*A*Y*Y~DTP*431*D8*20010201~REF*EA*KNOWIL0003~HI*BK:3
384*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX
*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99211:25*29*UN*1**01*1:2~DTP*472*D
8*20131017~REF*6R*ZZZZZ008PM~LX*2~SV1*HC:62369*180*UN*1**01*1~DTP*472*D8*2013101
7~REF*6R*ZZZZZ008PN~LX*3~SV1*HC:J7799:KD::::FENTANYL 51927101900 MORPHINE 519271
0000*500*UN*1**01*1:2~DTP*472*D8*20131017~REF*6R*ZZZZZ008PO~NTE*ADD*NTE FENTANYL
154.00 MG/ML MRPHINE 22.03 MG/ML~LIN**N4*51927101900~CTP****1*UN~LX*4~SV1*HC:A4
420*30*UN*1**09*2~DTP*472*D8*20131017~REF*6R*ZZZZZ008PP~HL*92**20*1~NM1*85*2*DON
ALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANT
ONIO*TX*782583916~REF*EI*300780099~HL*93*92*22*1~SBR*P**199409******CI~NM1*IL*1*
WARNER*NATHANIEL****MI*907991383~NM1*PR*2*UNITED HEALTHCARE*****PI*87726~N3*PO B
OX 740800~N4*ATLANTA*GA*303740800~HL*94*93*23*0~PAT*01~NM1*QC*1*WARNER*SUZAN~N3*
170 LOS COLINAS~N4*SPRING BRANCH*TX*78070~DMG*D8*19560821*F~CLM*2399*1880***11:B
:1*Y*A*Y*Y~DTP*431*D8*20130709~REF*9F*6673534201~REF*EA*WARSUZ0001~HI*BK:3384*BF
:7840*BF:7231~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*
S*01*NONE******CH~OI***Y***Y~NM1*IL*1*WARNER*NATHANIEL****MI*454984961~N3*170 LO
S COLINAS~N4*SPRING BRANCH*TX*78070~REF*SY*462041502~NM1*PR*2*TRICARE SOUTH*****
PI*61125~N3*PO BOX 7031~N4*CAMDEN*SC*29020~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3~
DTP*472*D8*20131014~REF*6R*ZZZZZ008QX~LX*2~SV1*HC:J2250*4*UN*4**02*1:2:3~DTP*472

*D8*20131014~REF*6R*ZZZZZ008QZ~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885
*60*UN*4**02*1:2:3~DTP*472*D8*20131014~REF*6R*ZZZZZ008R0~LIN**N4*00409379501~CTP
****15*UN~LX*4~SV1*HC:J3490:::::KETAMINE NDC409205105*1600*UN*40**02*1:2:3~DTP*4
72*D8*20131014~REF*6R*ZZZZZ008R1~NTE*ADD*NTE KETAMINE 400 MG/ML~LIN**N4*00409205
105~CTP****1*UN~LX*5~SV1*HC:J2405*8*UN*4**02*1:2:3~DTP*472*D8*20131014~REF*6R*ZZ
ZZZ008R2~LIN**N4*00691340020~CTP****1*UN~LX*6~SV1*HC:96366*93*UN*3**02*1:2:3~DTP
*472*D8*20131014~REF*6R*ZZZZZ008R3~LX*7~SV1*HC:J7030*10*UN*1**02*1:2:3~DTP*472*D
8*20131014~REF*6R*ZZZZZ008R4~HL*95**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*16
89018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*30
0780099~HL*96*95*22*1~SBR*P**199409******CI~NM1*IL*1*WARNER*NATHANIEL****MI*9079
91383~NM1*PR*2*UNITED HEALTHCARE*****PI*87726~N3*PO BOX 740800~N4*ATLANTA*GA*303
740800~HL*97*96*23*0~PAT*01~NM1*QC*1*WARNER*SUZAN~N3*170 LOS COLINAS~N4*SPRING B
RANCH*TX*78070~DMG*D8*19560821*F~CLM*2400*2073***11:B:1*Y*A*Y*Y~DTP*431*D8*20130
709~REF*9F*6673534201~REF*EA*WARSUZ0001~HI*BK:3384*BF:7840*BF:7231~NM1*82*1*BACO
N*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SBR*S*01*NONE******CH~OI***Y***
Y~NM1*IL*1*WARNER*NATHANIEL****MI*454984961~N3*170 LOS COLINAS~N4*SPRING BRANCH*
TX*78070~REF*SY*462041502~NM1*PR*2*TRICARE SOUTH*****PI*61125~N3*PO BOX 7031~N4*
CAMDEN*SC*29020~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3~DTP*472*D8*20131015~REF*6R*
ZZZZZ008R6~LX*2~SV1*HC:J2250*5*UN*5**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ00
8R7~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN*4**02*1:2:3~DTP*472*
D8*20131015~REF*6R*ZZZZZ008R8~LIN**N4*00409379501~CTP****15*UN~LX*4~SV1*HC:J3490
:::::KETAMINE NDC409205105*1800*UN*45**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ
008R9~NTE*ADD*NTE KETAMINE 450 MG/ML~LIN**N4*00409205105~CTP****1*UN~LX*5~SV1*HC
:96366*93*UN*3**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008RA~LX*6~SV1*HC:J7030
*10*UN*1**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008RB~HL*98**20*1~NM1*85*2*DO
NALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN AN
TONIO*TX*782583916~REF*EI*300780099~HL*99*98*22*1~SBR*P**199409******CI~NM1*IL*1
*WARNER*NATHANIEL****MI*907991383~NM1*PR*2*UNITED HEALTHCARE*****PI*87726~N3*PO
BOX 740800~N4*ATLANTA*GA*303740800~HL*100*99*23*0~PAT*01~NM1*QC*1*WARNER*SUZAN~N
3*170 LOS COLINAS~N4*SPRING BRANCH*TX*78070~DMG*D8*19560821*F~CLM*2401*2274***11
:B:1*Y*A*Y*Y~DTP*431*D8*20130709~REF*9F*6673534201~REF*EA*WARSUZ0001~HI*BK:3384*
BF:7840*BF:7231~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~SB
R*S*01*NONE******CH~OI***Y***Y~NM1*IL*1*WARNER*NATHANIEL****MI*454984961~N3*170
LOS COLINAS~N4*SPRING BRANCH*TX*78070~REF*SY*462041502~NM1*PR*2*TRICARE SOUTH***
**PI*61125~N3*PO BOX 7031~N4*CAMDEN*SC*29020~LX*1~SV1*HC:96365*105*UN*1**02*1~DT
P*472*D8*20131016~REF*6R*ZZZZZ008RE~LX*2~SV1*HC:J2250*6*UN*6**02*1~DTP*472*D8*20
131016~REF*6R*ZZZZZ008RF~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN
*4**02*1~DTP*472*D8*20131016~REF*6R*ZZZZZ008RG~LIN**N4*00409379501~CTP****15*UN~
LX*4~SV1*HC:J3490:::::KETAMINE NDC409205105*2000*UN*50**02*1~DTP*472*D8*20131016
~REF*6R*ZZZZZ008RH~NTE*ADD*NTE KETAMINE 500 MG/ML~LIN**N4*00409205105~CTP****1*U
N~LX*5~SV1*HC:96366*93*UN*3**02*1~DTP*472*D8*20131016~REF*6R*ZZZZZ008RI~LX*6~SV1
*HC:J7030*10*UN*1**02*1~DTP*472*D8*20131016~REF*6R*ZZZZZ008RJ~HL*101**20*1~NM1*8
5*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*
SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*102*101*22*1~SBR*P**199409******CI~
NM1*IL*1*WARNER*NATHANIEL****MI*907991383~NM1*PR*2*UNITED HEALTHCARE*****PI*8772
6~N3*PO BOX 740800~N4*ATLANTA*GA*303740800~HL*103*102*23*0~PAT*01~NM1*QC*1*WARNE
R*SUZAN~N3*170 LOS COLINAS~N4*SPRING BRANCH*TX*78070~DMG*D8*19560821*F~CLM*2402*
2474***11:B:1*Y*A*Y*Y~DTP*431*D8*20130709~REF*9F*6673534201~REF*EA*WARSUZ0001~HI
*BK:3384*BF:7840*BF:7231~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*1744
00000X~SBR*S*01*NONE******CH~OI***Y***Y~NM1*IL*1*WARNER*NATHANIEL****MI*45498496
1~N3*170 LOS COLINAS~N4*SPRING BRANCH*TX*78070~REF*SY*462041502~NM1*PR*2*TRICARE
SOUTH*****PI*61125~N3*PO BOX 7031~N4*CAMDEN*SC*29020~LX*1~SV1*HC:96365*105*UN*1
**02*1~DTP*472*D8*20131017~REF*6R*ZZZZZ008RL~LX*2~SV1*HC:J2250*6*UN*6**02*1~DTP*
472*D8*20131017~REF*6R*ZZZZZ008RN~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1
885*60*UN*4**02*1~DTP*472*D8*20131017~REF*6R*ZZZZZ008RO~LIN**N4*00409379501~CTP*
***15*UN~LX*4~SV1*HC:J3490:::::KETAMINE NDC409205105*2200*UN*55**02*1~DTP*472*D8
*20131017~REF*6R*ZZZZZ008RP~NTE*ADD*NTE KETAMINE 550 MG/ML~LIN**N4*00409205105~C
TP****1*UN~LX*5~SV1*HC:96366*93*UN*3**02*1~DTP*472*D8*20131017~REF*6R*ZZZZZ008RQ
~LX*6~SV1*HC:J7030*10*UN*1**02*1~DTP*472*D8*20131017~REF*6R*ZZZZZ008RR~HL*104**2
0*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUIT

E 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*105*104*22*1~SBR*P**NONE**
****CH~NM1*IL*1*ARNOLD*DAVID****MI*464271081~NM1*PR*2*TRICARE SOUTH*****PI*61125
~N3*PO BOX 7031~N4*CAMDEN*SC*29020~HL*106*105*23*0~PAT*01~NM1*QC*1*ARNOLD*DAWN~N
3*324 LOST TRAIL CIR~N4*LA VERNIA*TX*78121~DMG*D8*19720721*F~CLM*2394*1273***11:
B:1*Y*A*Y*Y~DTP*431*D8*20130919~REF*EA*ARNDAW0001~HI*BK:3384*BF:7242*BF:7295~NM1
*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV
*PE*PXC*174400000X~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3~DTP*472*D8*20131014~REF*
6R*ZZZZZ008PU~LX*2~SV1*HC:J2250*5*UN*5**02*1:2:3~DTP*472*D8*20131014~REF*6R*ZZZZ
Z008PW~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN*4**02*1:2:3~DTP*4
72*D8*20131014~REF*6R*ZZZZZ008PX~LIN**N4*00409379501~CTP****15*UN~LX*4~SV1*HC:J3
490:::::KETAMINE NDC409205105*1000*UN*25**02*1:2:3~DTP*472*D8*20131014~REF*6R*ZZ
ZZZ008PY~NTE*ADD*NTE KETAMINE 250 MG/ML~LIN**N4*00409205105~CTP****1*UN~LX*5~SV1
*HC:96366*93*UN*3**02*1:2:3~DTP*472*D8*20131014~REF*6R*ZZZZZ008PZ~LX*6~SV1*HC:J7
030*10*UN*1**02*1:2:3~DTP*472*D8*20131014~REF*6R*ZZZZZ008Q2~HL*107**20*1~NM1*85*
2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SA
N ANTONIO*TX*782583916~REF*EI*300780099~HL*108*107*22*1~SBR*P**NONE******CH~NM1*
IL*1*ARNOLD*DAVID****MI*464271081~NM1*PR*2*TRICARE SOUTH*****PI*61125~N3*PO BOX
7031~N4*CAMDEN*SC*29020~HL*109*108*23*0~PAT*01~NM1*QC*1*ARNOLD*DAWN~N3*324 LOST
TRAIL CIR~N4*LA VERNIA*TX*78121~DMG*D8*19720721*F~CLM*2395*1481***11:B:1*Y*A*Y*Y
~DTP*431*D8*20130919~REF*EA*ARNDAW0001~HI*BK:3384*BF:7242*BF:7295~NM1*DN*1*BACON
*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174
400000X~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008
Q3~LX*2~SV1*HC:J2250*5*UN*5**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008Q4~LIN*
*N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN*4**02*1:2:3~DTP*472*D8*20131
015~REF*6R*ZZZZZ008Q5~LIN**N4*00409379501~CTP****15*UN~LX*4~SV1*HC:J3490:::::KET
AMINE NDC409205105*1200*UN*30**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008Q6~NT
E*ADD*NTE KETAMINE 300 MG/ML~LIN**N4*00409205105~CTP****1*UN~LX*5~SV1*HC:J2405*8
*UN*4**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008Q7~LIN**N4*00691340020~CTP***
*1*UN~LX*6~SV1*HC:96366*93*UN*3**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008Q8~
LX*7~SV1*HC:J7030*10*UN*1**02*1:2:3~DTP*472*D8*20131015~REF*6R*ZZZZZ008Q9~HL*110
**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE S
UITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*111*110*22*1~SBR*P**NON
E******CH~NM1*IL*1*ARNOLD*DAVID****MI*464271081~NM1*PR*2*TRICARE SOUTH*****PI*61
125~N3*PO BOX 7031~N4*CAMDEN*SC*29020~HL*112*111*23*0~PAT*01~NM1*QC*1*ARNOLD*DAW
N~N3*324 LOST TRAIL CIR~N4*LA VERNIA*TX*78121~DMG*D8*19720721*F~CLM*2397*1690***
11:B:1*Y*A*Y*Y~DTP*431*D8*20130919~REF*EA*ARNDAW0001~HI*BK:3384*BF:7242*BF:7295~
NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~
PRV*PE*PXC*174400000X~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3~DTP*472*D8*20131016~R
EF*6R*ZZZZZ008QI~LX*2~SV1*HC:J2250*6*UN*6**02*1:2:3~DTP*472*D8*20131016~REF*6R*Z
ZZZZ008QJ~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN*4**02*1:2:3~DT
P*472*D8*20131016~REF*6R*ZZZZZ008QK~LIN**N4*00409379501~CTP****15*UN~LX*4~SV1*HC
:J3490:::::KETAMINE NDC409205105*1400*UN*35**02*1:2:3~DTP*472*D8*20131016~REF*6R
*ZZZZZ008QL~NTE*ADD*NTE KETAMINE 350 MG/ML~LIN**N4*00409205105~CTP****1*UN~LX*5~
SV1*HC:J2405*16*UN*8**02*1:2:3~DTP*472*D8*20131016~REF*6R*ZZZZZ008QM~LIN**N4*006
91340020~CTP****1*UN~LX*6~SV1*HC:96366*93*UN*3**02*1:2:3~DTP*472*D8*20131016~REF
*6R*ZZZZZ008QN~LX*7~SV1*HC:J7030*10*UN*1**02*1:2:3~DTP*472*D8*20131016~REF*6R*ZZ
ZZZ008QO~HL*113**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK
CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*114*113*
22*1~SBR*P**NONE******CH~NM1*IL*1*ARNOLD*DAVID****MI*464271081~NM1*PR*2*TRICARE
SOUTH*****PI*61125~N3*PO BOX 7031~N4*CAMDEN*SC*29020~HL*115*114*23*0~PAT*01~NM1*
QC*1*ARNOLD*DAWN~N3*324 LOST TRAIL CIR~N4*LA VERNIA*TX*78121~DMG*D8*19720721*F~C
LM*2398*1890***11:B:1*Y*A*Y*Y~DTP*431*D8*20130919~REF*EA*ARNDAW0001~HI*BK:3384*B
F:7242*BF:7295~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D**
*XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3~DTP*47
2*D8*20131017~REF*6R*ZZZZZ008QP~LX*2~SV1*HC:J2250*6*UN*6**02*1:2:3~DTP*472*D8*20
131017~REF*6R*ZZZZZ008QQ~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN
*4**02*1:2:3~DTP*472*D8*20131017~REF*6R*ZZZZZ008QR~LIN**N4*00409379501~CTP****15
*UN~LX*4~SV1*HC:J3490:::::KETAMINE NDC409205105*1600*UN*40**02*1:2:3~DTP*472*D8*
20131017~REF*6R*ZZZZZ008QS~LIN**N4*00409205105~CTP****1*UN~LX*5~SV1*HC:J2405*16*
UN*8**02*1:2:3~DTP*472*D8*20131017~REF*6R*ZZZZZ008QT~LIN**N4*00691340020~CTP****

1*UN~LX*6~SV1*HC:96366*93*UN*3**02*1:2:3~DTP*472*D8*20131017~REF*6R*ZZZZZ008QU~L
X*7~SV1*HC:J7030*10*UN*1**02*1:2:3~DTP*472*D8*20131017~REF*6R*ZZZZZ008QV~HL*116*
*20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SU
ITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*117*116*22*0~SBR*P*18***
****MB~NM1*IL*1*NELSON*TERRY*T***MI*530434669A~N3*30821 PANTHER DRIVE~N4*BULVERD
E*TX*78163~DMG*D8*19870724*M~NM1*PR*2*MEDICARE*****PI*00156~N3*POB 890108~N4*CAM
P HILL*PA*170890108~REF*FY*85525287~CLM*2411*342***11:B:1*Y*A*Y*Y~DTP*431*D8*201
31017~REF*X4*45D2058148~REF*EA*NELTER0001~HI*BK:33821*BF:7840*BF:71941*BF:71831*
BF:8405~NM1*DN*1*MANDRELL*RONALD~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*
PXC*174400000X~SBR*S*01*NONE******CH~OI***Y***Y~NM1*IL*1*NELSON*REGINA****MI*250
956656~N3*30821 PANTHER DR~N4*BULVERDE*TX*78163~NM1*PR*2*TRICARE PRIME*****PI*00
011~N3*P O BOX 7031~N4*CAMDEN*SC*29020~LX*1~SV1*HC:99205*292*UN*1**01*1:2:3:4~DT
P*472*D8*20131018~REF*6R*ZZZZZ008TG~LX*2~SV1*HC:97535*50*UN*1**I*1:2:3:4~DTP*472
*D8*20131018~REF*6R*ZZZZZ008TH~HL*118**20*1~NM1*85*2*DONALD D BACON MD PA*****XX
*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI
*300780099~HL*119*118*22*1~SBR*P**503777******CI~NM1*IL*1*RAY*EDWARD****MI*83673
2438~NM1*PR*2*UNITED HEALTHCARE*****PI*87726~N3*PO BOX 740800~N4*ATLANTA*GA*3037
40800~HL*120*119*23*0~PAT*01~NM1*QC*1*RAY*KERRY*L~N3*18126 BEARGRASS COURT~N4*SA
N ANTONIO*TX*78258~DMG*D8*19601115*F~CLM*2338*935***11:B:1*Y*A*Y*Y~DTP*431*D8*20
130926~REF*EA*RAYKER0001~HI*BK:3384*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502
284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:64
483:RT*375*UN*1**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IE~LX*2~SV1*HC:J3010*50
*UN*50**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008II~LIN**N4*00409909422~CTP****1*
UN~LX*3~SV1*HC:Q9962*10*UN*10**09*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IL~LIN**N
4*00407141361~CTP****1*UN~LX*4~SV1*HC:J2250*5*UN*1**02*2~DTP*472*D8*20131015~REF
*6R*ZZZZZ008IM~LIN**N4*00409258705~CTP****1*UN~LX*5~SV1*HC:64484:LT*300*UN*1**02
*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IN~LX*6~SV1*HC:J0702*15*UN*15**02*2~DTP*47
2*D8*20131015~REF*6R*ZZZZZ008IP~LIN**N4*00517072001~CTP****1*UN~LX*7~SV1*HC:J349
0:::::PROPOFOL 10ML*180*UN*12**02*2~DTP*472*D8*20131015~REF*6R*ZZZZZ008IQ~NTE*AD
D*NTE PROPFOL 120 MG/ML~LIN**N4*00409469930~CTP****10*UN~HL*121**20*1~NM1*85*2*D
ONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN A
NTONIO*TX*782583916~REF*EI*300780099~HL*122*121*22*1~SBR*P**712983******CI~NM1*I
L*1*NARUP*FRANK****MI*956878778~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO B
OX 30557~N4*SALT LAKE CITY*UT*841300557~HL*123*122*23*0~PAT*01~NM1*QC*1*NARUP*CH
RISTINA~N3*6566 BEECH TRAIL~N4*CONVERSE*TX*78109~DMG*D8*19760706*F~CLM*2403*3491
***11:B:1*Y*A*Y*Y~DTP*431*D8*20130613~REF*EA*NARCHR0001~HI*BK:3384*BF:7295*BF:78
096*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX
*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3:4~DTP*472
*D8*20131014~REF*6R*ZZZZZ008RT~LX*2~SV1*HC:J2250*7*UN*7**02*1:2:3:4~DTP*472*D8*2
0131014~REF*6R*ZZZZZ008RU~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*U
N*4**02*1:2:3:4~DTP*472*D8*20131014~REF*6R*ZZZZZ008RV~LIN**N4*00409379501~CTP***
*15*UN~LX*4~SV1*HC:J3490:::::KETAMINE NDC409205105*3200*UN*80**02*1:2:3:4~DTP*47
2*D8*20131014~REF*6R*ZZZZZ008RW~NTE*ADD*NTE KETAMINE 800 MG/ML~LIN**N4*004092051
05~CTP****1*UN~LX*5~SV1*HC:J2405*16*UN*8**02*1:2:3:4~DTP*472*D8*20131014~REF*6R*
ZZZZZ008RX~LIN**N4*00691340020~CTP****1*UN~LX*6~SV1*HC:96366*93*UN*3**02*1:2:3:4
~DTP*472*D8*20131014~REF*6R*ZZZZZ008RY~LX*7~SV1*HC:J7030*10*UN*1**02*1:2:3:4~DTP
*472*D8*20131014~REF*6R*ZZZZZ008RZ~HL*124**20*1~NM1*85*2*DONALD D BACON MD PA***
**XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~RE
F*EI*300780099~HL*125*124*22*1~SBR*P**712983******CI~NM1*IL*1*NARUP*FRANK****MI*
956878778~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO BOX 30557~N4*SALT LAKE
CITY*UT*841300557~HL*126*125*23*0~PAT*01~NM1*QC*1*NARUP*CHRISTINA~N3*6566 BEECH
TRAIL~N4*CONVERSE*TX*78109~DMG*D8*19760706*F~CLM*2404*3490***11:B:1*Y*A*Y*Y~DTP*
431*D8*20130613~REF*EA*NARCHR0001~HI*BK:3384*BF:7295*BF:78096*BF:7242~NM1*DN*1*B
ACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC
*174400000X~LX*1~SV1*HC:96365*105*UN*1**02*1:2:3:4~DTP*472*D8*20131015~REF*6R*ZZ
ZZZ008S1~LX*2~SV1*HC:J2250*6*UN*6**02*1:2:3:4~DTP*472*D8*20131015~REF*6R*ZZZZZ00
8S2~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN*4**02*1:2:3:4~DTP*47
2*D8*20131015~REF*6R*ZZZZZ008S3~LIN**N4*00409379501~CTP****15*UN~LX*4~SV1*HC:J34
90:::::KETAMINE NDC409205105*3200*UN*80**02*1:2:3:4~DTP*472*D8*20131015~REF*6R*Z
ZZZZ008S4~NTE*ADD*NTE KETAMINE 800 MG/ML~LIN**N4*00409205105~CTP****1*UN~LX*5~SV

1*HC:J2405*16*UN*8**02*1:2:3:4~DTP*472*D8*20131015~REF*6R*ZZZZZ008S5~LIN**N4*006
91340020~CTP****1*UN~LX*6~SV1*HC:96366*93*UN*3**02*1:2:3:4~DTP*472*D8*20131015~R
EF*6R*ZZZZZ008S6~LX*7~SV1*HC:J7030*10*UN*1**02*1:2:3:4~DTP*472*D8*20131015~REF*6
R*ZZZZZ008S7~HL*127**20*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525
OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*128*
127*22*1~SBR*P**712983******CI~NM1*IL*1*NARUP*FRANK****MI*956878778~NM1*PR*2*UNI
TED HEALTH CARE*****PI*87726~N3*PO BOX 30557~N4*SALT LAKE CITY*UT*841300557~HL*1
29*128*23*0~PAT*01~NM1*QC*1*NARUP*CHRISTINA~N3*6566 BEECH TRAIL~N4*CONVERSE*TX*7
8109~DMG*D8*19760706*F~CLM*2405*3490***11:B:1*Y*A*Y*Y~DTP*431*D8*20130613~REF*EA
*NARCHR0001~HI*BK:3384*BF:7295*BF:78096*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*197
2502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*H
C:96365*105*UN*1**02*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008S9~LX*2~SV1*HC:J
2250*6*UN*6**02*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008SA~LIN**N4*0040923051
7~CTP****1*UN~LX*3~SV1*HC:J1885*60*UN*4**02*1:2:3:4~DTP*472*D8*20131016~REF*6R*Z
ZZZZ008SB~LIN**N4*00409379501~CTP****15*UN~LX*4~SV1*HC:J3490:::::KETAMINE NDC409
205105*3200*UN*80**02*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008SC~NTE*ADD*NTE
KETAMINE 800 MG/ML~LIN**N4*00409205105~CTP****1*UN~LX*5~SV1*HC:J2405*16*UN*8**02
*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008SD~LIN**N4*00691340020~CTP****1*UN~L
X*6~SV1*HC:96366*93*UN*3**02*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008SE~LX*7~
SV1*HC:J7030*10*UN*1**02*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008SF~HL*130**2
0*1~NM1*85*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUIT
E 140~N4*SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*131*130*22*1~SBR*P**712983
******CI~NM1*IL*1*NARUP*FRANK****MI*956878778~NM1*PR*2*UNITED HEALTH CARE*****PI
*87726~N3*PO BOX 30557~N4*SALT LAKE CITY*UT*841300557~HL*132*131*23*0~PAT*01~NM1
*QC*1*NARUP*CHRISTINA~N3*6566 BEECH TRAIL~N4*CONVERSE*TX*78109~DMG*D8*19760706*F
~CLM*2406*3692***11:B:1*Y*A*Y*Y~DTP*431*D8*20130613~REF*EA*NARCHR0001~HI*BK:3384
*BF:7295*BF:78096*BF:7242~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON
*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:96365*105*UN*1**02*1
:2:3:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008SH~LX*2~SV1*HC:J2250*8*UN*8**02*1:2:3:
4~DTP*472*D8*20131017~REF*6R*ZZZZZ008SI~LIN**N4*00409230517~CTP****1*UN~LX*3~SV1
*HC:J1885*60*UN*4**02*1:2:3:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008SJ~LIN**N4*0040
9379501~CTP****15*UN~LX*4~SV1*HC:J3490:::::KETAMINE NDC409205105*3400*UN*85**02*
1:2:3:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008SK~NTE*ADD*NTE KETAMINE 850 MG/ML~LIN
**N4*00409205105~CTP****1*UN~LX*5~SV1*HC:J2405*16*UN*8**02*1:2:3:4~DTP*472*D8*20
131017~REF*6R*ZZZZZ008SL~LIN**N4*00691340020~CTP****1*UN~LX*6~SV1*HC:96366*93*UN
*3**02*1:2:3:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008SM~LX*7~SV1*HC:J7030*10*UN*1**
02*1:2:3:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008SN~HL*133**20*1~NM1*85*2*DONALD D
BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*T
X*782583916~REF*EI*300780099~HL*134*133*22*0~SBR*P*18*104******BL~NM1*IL*1*KIDWE
LL*CYNTHIA*L***MI*R58305004~N3*1412 POLLY LANE~N4*LA VERNIA*TX*78121~DMG*D8*1954
0611*F~NM1*PR*2*BLUE CROSS BLUE SHIELD FEDERAL*****PI*00900~N3*P O BOX 660044~N4
*DALLAS*TX*75266~CLM*2353*193***11:B:1*Y*A*Y*Y~DTP*431*D8*20131014~REF*EA*KIDCYN
0001~HI*BK:3384*BF:7242*BF:7244*BF:7213*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*19
72502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*
HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008KX~LX*2~SV1*HC:
80104*40*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ008KY~HL*135**20*1~NM1*85*
2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SA
N ANTONIO*TX*782583916~REF*EI*300780099~HL*136*135*22*1~SBR*P**108928******BL~NM
1*IL*1*BEECHER*WILLIAM****MI*ZGP838054186~NM1*PR*2*BLUE CROSS BLUE SHIELD*****PI
*00900~N3*P O BOX 660044~N4*DALLAS*TX*75266~HL*137*136*23*0~PAT*01~NM1*QC*1*BEEC
HER*MARY~N3*1211 BELCLAIRE~N4*SAN ANTONIO*TX*78258~DMG*D8*19710120*F~CLM*2366*19
3***11:B:1*Y*A*Y*Y~DTP*431*D8*20130711~REF*EA*BEEMAR0001~HI*BK:3384*BF:7242*BF:7
295*BF:7244*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*1972502284~NM1*82*1*BACON*DONA
LD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1*HC:99214*153*UN*1**01*1:2:3:
4~DTP*472*D8*20131016~REF*6R*ZZZZZ008LU~LX*2~SV1*HC:80104*40*UN*1**05*1:5~DTP*47
2*D8*20131016~REF*6R*ZZZZZ008LV~HL*138**20*1~NM1*85*2*DONALD D BACON MD PA*****X
X*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*SAN ANTONIO*TX*782583916~REF*E
I*300780099~HL*139*138*22*1~SBR*P**NONE******CI~NM1*IL*2*US POSTAL SERVICE~NM1*P
R*2*DEPT OF LABOR/OWCP*****PI*77044~N3*P O BOX 8300~N4*LONDON*KY*407428300~HL*14
0*139*23*0~PAT*G8~NM1*QC*1*HARRELL*FRANK~N3*9526 AQUA VERDE~N4*HELOTES*TX*78023~

DMG*D8*19590310*M~CLM*2357*193***11:B:1*Y*A*Y*Y~DTP*431*D8*19970415~REF*EA*HARFR
A0002~HI*BK:3384*BF:7231*BF:72281*BF:7291*BF:V5869~NM1*DN*1*BACON*DONALD*D***XX*
1972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV
1*HC:99214*153*UN*1**01*1:2:3:4~DTP*472*D8*20131016~REF*6R*ZZZZZ008L3~LX*2~SV1*H
C:80104*40*UN*1**05*1:5~DTP*472*D8*20131016~REF*6R*ZZZZZ008L4~HL*141**20*1~NM1*8
5*2*DONALD D BACON MD PA*****XX*1689018079~N3*525 OAK CENTRE DRIVE SUITE 140~N4*
SAN ANTONIO*TX*782583916~REF*EI*300780099~HL*142*141*22*0~SBR*P*18*702393******C
I~NM1*IL*1*DEINES*CHRISTOPHER*J***MI*945167067~N3*27550 RAMBLEWOOD~N4*SAN ANTONI
O*TX*78261~DMG*D8*19570925*M~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*P O BOX
30555~N4*SALT LAKE CITY*UT*841300555~CLM*2390*292***11:B:1*Y*A*Y*Y~REF*EA*DEICH
R0001~HI*BK:3384*BF:7242*BF:7213*BF:72210*BF:7244~NM1*DN*1*BACON*DONALD*D***XX*1
972502284~NM1*82*1*BACON*DONALD*D***XX*1972502284~PRV*PE*PXC*174400000X~LX*1~SV1
*HC:99205*292*UN*1**01*1:2:3:4~DTP*472*D8*20131017~REF*6R*ZZZZZ008PG~SE*2988*000
000632~GE*1*632~IEA*1*000000632~