NIST NCPDP Analysis - SCRIPT 10.6 Message Examples

Table of Contents

Coumadin 2 mg tab | Dispensed drug 1 

Celebrex 50 mg capsule | Dispensed drug 2 

Lipitor 40 mg tablet | Dispensed drug 3 

Caltrate 1500 mg tablet | Dispensed drug 4 

Coumadin 2 mg tab | Dispensed drug 5 

Celebrex 50 mg capsule | Dispensed drug 6 

Lipitor 40 mg tablet | Dispensed drug 7 

Caltrate 1500 mg tablet | Dispensed drug 8 

Coumadin 2 mg tab | Dispensed drug 9 

Celebrex 50 mg capsule | Dispensed drug 10 

Lipitor 40 mg tablet | Dispensed drug 11 

Caltrate 1500 mg tablet | Dispensed drug 12 

Coumadin 2 mg tab | Dispensed drug 13 

Celebrex 50 mg capsule | Dispensed drug 14 

Lipitor 40 mg tablet | Dispensed drug 15 

Caltrate 1500 mg tablet | Dispensed drug 16 

Coumadin 2 mg tab | Dispensed drug 17 

Celebrex 50 mg capsule | Dispensed drug 18 

Lipitor 40 mg tablet | Dispensed drug 19 

Caltrate 1500 mg tablet | Dispensed drug 20 

Coumadin 2 mg tab | Dispensed drug 21 

Celebrex 50 mg capsule | Dispensed drug 22 

Lipitor 40 mg tablet | Dispensed drug 23 

Caltrate 1500 mg tablet | Dispensed drug 24 

Lopressor 50mg tab | Dispensed drug 1 

Lopressor 50mg tab | Dispensed drug 2 

Lopressor 50mg tab | Dispensed drug 3 

Lopressor 50mg tab | Dispensed drug 4 

Lopressor 50mg tab | Dispensed drug 5 

Lopressor 50mg tab | Dispensed drug 6 

Lopressor 50mg tab | Dispensed drug 7 

Lopressor 50mg tab | Dispensed drug 8 

Lopressor 50mg tab | Dispensed drug 9 

Lopressor 50mg tab | Dispensed drug 10 

Lopressor 50mg tab | Dispensed drug 11 

Lopressor 50mg tab | Dispensed drug 12 

Crestor 10 mg tab | Dispensed drug 13 

Crestor 10 mg tab | Dispensed drug 14 

Crestor 10 mg tab | Dispensed drug 15 

Crestor 10 mg tab | Dispensed drug 16 

Crestor 10 mg tab | Dispensed drug 17 

Crestor 10 mg tab | Dispensed drug 18 

Crestor 10 mg tab | Dispensed drug 19 

Crestor 10 mg tab | Dispensed drug 20 

Crestor 10 mg tab | Dispensed drug 21 

Crestor 10 mg tab | Dispensed drug 22 

Vasotec 5 mg tab | Dispensed drug 23 

Vasotec 5 mg tab | Dispensed drug 24 

Vasotec 5 mg tab | Dispensed drug 25 

Vasotec 5 mg tab | Dispensed drug 26 

Vasotec 5 mg tab | Dispensed drug 27 

Scenario: 1: Medication History - Request | Geriatric | Facility discharge | Matilda Doe 

Scenario: 1: Medication History - Response | 4 meds - 24 dispenses | Facility discharge | Matilda Doe 

Scenario: 1: New Prescription - Coumadin 2 mg tablet | Geriatric w Structured Sig | Facility discharge | Matilda Doe 

Scenario: 1: New Prescription - MS Contin 30 mg tablet | Controlled substance | Facility discharge | Matilda Doe 

Scenario: 1: New Prescription - Senokot-S 50 mg tablet | Geriatric | Facility discharge | Matilda Doe 

Scenario: 3: Medication History - Request | 4 meds with 46 dispenses | Hospital discharge | John Doe 

Scenario: 3: Medication History - Response | 4 meds / 46 dispenses | Hospital discharge | John Doe 

 © 1st American Systems and Services | www.1asas.com Page 1 of 206 Printed: 8/22/2012 10:24 PM
Vasotec 5 mg tab | Dispensed drug 28 

Vasotec 5 mg tab | Dispensed drug 29 

Vasotec 5 mg tab | Dispensed drug 30 

Vasotec 5 mg tab | Dispensed drug 31 

Vasotec 5 mg tab | Dispensed drug 32 

Vasotec 5 mg tab | Dispensed drug 33 

Vasotec 5 mg tab | Dispensed drug 34 

Advair inhaler | Dispensed drug 35 

Advair inhaler | Dispensed drug 36 

Advair inhaler | Dispensed drug 37 

Advair inhaler | Dispensed drug 38 

Advair inhaler | Dispensed drug 39 

Advair inhaler | Dispensed drug 40 

Advair inhaler | Dispensed drug 41 

Advair inhaler | Dispensed drug 42 

Advair inhaler | Dispensed drug 43 

Advair inhaler | Dispensed drug 44 

Advair inhaler | Dispensed drug 45 

Advair inhaler | Dispensed drug 46 

Triphasil-21 | Dispensed drug 1 

Triphasil-21 | Dispensed drug 2 

Triphasil-21 | Dispensed drug 3 

Triphasil-21 | Dispensed drug 4 

Triphasil-21 | Dispensed drug 5 

Triphasil-21 | Dispensed drug 6 

Triphasil-21 | Dispensed drug 7 

Triphasil-21 | Dispensed drug 8 

Triphasil-21 | Dispensed drug 9 

Triphasil-21 | Dispensed drug 10 

Triphasil-21 | Dispensed drug 11 

Triphasil-21 | Dispensed drug 12 

Multigen Plus | Dispensed drug 13 

Multigen Plus | Dispensed drug 14 

Multigen Plus | Dispensed drug 15 

Zyrtec 10 mg tab | Requested med 

Diclofenac 75 mg tab | Dispensed drug 

Scenario: 4: Refill Response - Lopressor 50 mg tab | Approved response | Ambulatory | John Doe 

Scenario: 3: New Prescription - Vasotec 5 mg tablet | Resident w/supervisor | Hospital discharge | John Doe 

Scenario: 3: New Prescription - Lopressor 50 mg tab | Resident w/supervisor | Hospital discharge | John Doe 

Scenario: 3: New Prescription - Crestor 10 mg tab | Resident w/supervisor | Hospital discharge | John Doe 

Scenario: 4: Refill Request - Lopressor 50 mg tab | Approved | Ambulatory | John Doe 

Scenario: 9: Medication History - Request | No medications found | Ambulatory | James Doe 

Scenario: 4: Refill Request - Advair inhaler | Denied | Ambulatory | John Doe 

Scenario: 4: Refill Response - Advair inhaler | Denied response | Ambulatory | John Doe 

Scenario: 5: Refill Request - Advair inhaler | Approved | Ambulatory | John Doe 

Scenario: 5: Refill Response - Advair inhaler | Approved response | Ambulatory | John Doe 

Scenario: 6: Medication History - Request | 2 medications found | Emergency Dept | Jane Doe 

Scenario: 6: Medication History - Response | 2 medications found | Emergency Dept | Jane Doe 

Scenario: 6: New Prescription - Deltasone tapered dose | Structured SIG | Emergency Dept | Jane Doe 

Scenario: 7: New Prescription - Allegra 60 mg tab | Simple dose | Ambulatory | Jane Doe 

Scenario: 7: New Prescription - EpiPen Injection | Take if needed | Ambulatory | Jane Doe 

Scenario: 8: Change Request - Allegra 60 mg tab | Prescribed med | Ambulatory | Jane Doe 

Scenario: 8: Change Response - Zyrtec 10 mg tab | Approved | Ambulatory | Jane Doe 

Scenario: 9: Medication History - Response | No medications found | Ambulatory | James Doe 

Scenario: 9: New Prescription - Diclofenac 75 mg tab | Simple dose | Ambulatory | James Doe 

Scenario: 10: Medication History - Request | 1 medication found | Ambulatory | Mary Doe 

Scenario: 10: Medication History - Response | 1 medication found | Ambulatory | Mary Doe 

Scenario: 10: New Prescription - Vaseretic 25 mg tab | Simple dose | Ambulatory | Mary Doe 

Scenario: 10: New Prescription - Diclofenac 75 mg tab | Simple dose | Ambulatory | Mary Doe 

Scenario: 11: New Prescription - Prednisone 5 mg tab | Tapered dose | Ambulatory | Amy Doe 

Scenario: 11: New Prescription - Diclofenac 75 mg tab | Simple dose | Ambulatory | Amy Doe 

Scenario: 12: New Prescription - Humulin N 3 ml syringe | Before meals | Ambulatory | Freddy Doe 

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Vasotec 5 mg | Highly populated 

Vasotec 5 mg | Highly populated 

Enalapril Maleate 5mg | Highly populated 

Enalapril Maleate 5mg | Highly populated 

SULFAMETHOXAZOLE 400MG TABLET | Requested med 

Vasotec 5 MG Tablet | Therapeutic IC - approved 

Cataflam 50 MG Tablet | Formulary interchange 

Response | Lightly populated - Bupropion 

Response | Lightly populated - Inderal 

Scenario: 13: Medication History - Response | No medications found | Ambulatory | Sammy Doe 

Scenario: 12: New Prescription - Humulin R solution | Sliding scale | Ambulatory | Freddy Doe 

Scenario: 13: Medication History - Request | Denied - Member Not Found | Ambulatory | Sammy Doe 

Scenario: 17: Medication History - Response | Highly populated | Ambulatory | Connie Doe 

Scenario: 13: New Prescription - Amoxicillin 50 mg/ml powd | Weight-based dose | Ambulatory | Sammy Doe 

Scenario: 13: Fill Status - Response w/prescribed | Generic substitution | Ambulatory | Sammy Doe 

Scenario: 14: New Prescription - Synthroid | Dispense as written | Ambulatory | Cindy Doe 

Scenario: 14: Refill Request - Synthroid | Approved with changes | Ambulatory | Cindy Doe 

Scenario: 14: Refill Response - Synthroid | Approved w/Chg resp | Ambulatory | John Doe 

Scenario: 15: New Prescription - Amoxicillin Suspension | Contains an error | Ambulatory | Susie Doe 

Scenario: 15: Error - Error | System error at receiver | Ambulatory | Susie Doe 

Scenario: 16: New Prescription - Amoxicillin Suspension | Includes Verify request | Ambulatory | Susie Doe 

Scenario: 16: Status - Status | Status preceding Verify | Ambulatory | Susie Doe 

Scenario: 16: Verify - Verify | With opt prescribed drug | Ambulatory | Susie Doe 

Scenario: 17: Medication History - Request | 4 dispenses over 6 mo | Ambulatory | Connie Doe 

Scenario: 24: Change Response - SULFAMETHOXAZOLE 400MG TABLET | Denied | Ambulatory | Dean Doe 

Scenario: 17: New Prescription - Enalapril Maleate 10 MG | Structured Sig & Obs | Ambulatory | Connie Doe 

Scenario: 17: Fill Status - Response w/prescribed | Dispense as written | Ambulatory | Connie Doe 

Scenario: 18: New Prescrption - Amoxil 500 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Scenario: 19: Cancel Prescription - Amoxil 500 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Scenario: 19: Cancel Response - Amoxil 500 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Scenario: 20: New Prescrption - Zithromax 250 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Scenario: 21: New Prescription - Vicodin 10/660 | Controlled substance III | Ambulatory | Albert Doe 

Scenario: 22: Cancel Prescription - Vicodin 10/660 | Controlled substance III | Ambulatory | Albert Doe 

Scenario: 22: Cancel Response - Vicodin 10/660 | Controlled substance III | Ambulatory | Albert Doe 

Scenario: 23: New Prescription - Biaxin 250 MG Tablet | Simple directions | Ambulatory | Dean Doe 

Scenario: 24: Change Request - SULFAMETHOXAZOLE 400MG TABLET | Denied | Ambulatory | Dean Doe 

Scenario: 36: New Prescription - Celebrex 50 MG Capsule | Dispense as written | Pain medication | Amanda Doe 

Scenario: 24: New Prescription - Septra 400/80 Tablet | No Substitutions | Ambulatory | Dean Doe 

Scenario: 25: New Prescription - Biaxin 250 MG Tablet | DUE segment populated | Ambulatory | Terry Doe 

Scenario: 27: Census - Admission | with ALG and DIA | LTPAC | Frieda Doe 

Scenario: 29: Refill Request - Lasix 20 MG | Denied - new Rx to follow | Ambulatory | Cindy Doe 

Scenario: 29: Refill Response - Lasix 20 MG | Denied - new Rx to follow | Ambulatory | John Doe 

Scenario: 29: New Prescription - Furosemide 20mg Tab | Generic | Ambulatory | Colleen Doe 

Scenario: 33: Change Request - Voltaren 50 MG Tab | Request for prior auth | Ambulatory | Tabatha Doe 

Scenario: 33: Change Response - Voltaren 50 MG Tab | Request for prior auth | Ambulatory | Tabatha Doe 

Scenario: 34: New Prescrption - Hydrocot 50 MG Tab | Oral tablet | Ambulatory | Timothy Doe 

Scenario: 35: Change Request - Vasotec 5 MG Tablet | Therapeutic IC - approved | Ambulatory | Timothy Doe 

Scenario: 35: Change Response - Vasotec 5 MG Tablet | Therapeutic IC - approved | Ambulatory | Timothy Doe 

Scenario: 37: Change Request - Cataflam 50 MG Tablet | Formulary interchange | Ambulatory | Amanda Doe 

Scenario: 37: Change Response - Cataflam 50 MG Tablet | Formulary interchange | Ambulatory | Amanda Doe 

Scenario: 38: Medication History - Request | Lightly populated | Ambulatory | Martin Doe 

Scenario: 38: Medication History - Response | Lightliy Populated | Ambulatory | Martin Doe 

Scenario: 38: Census - Admission | with ALG and DIA | LTPAC | Martin Doe 

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Scenario: 1: Medication History - Request | Geriatric | Facility discharge | Matilda Doe 

Header

To PAYER100

From NPI9999999

MessageID 10001

SentTime 2011-01-02T10:15:40

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryRequest

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023426230

Qualifier TE

Patient 

Identification

MedicaidNumber FL

MedicareNumber DC123331

Name

LastName DOE

FirstName MATILDA

Gender F

DateOfBirth

Date 1927-09-03

Address

AddressLine1 1358-60 FLORIDA AVE NE

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2025888750

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName USA BENEFITS

CardholderID 100-19270903-01

ResponsibileParty

LastName DOE

FirstName MATILDA

EffectiveDate

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Date 2010-07-02

ExpirationDate

Date 2011-01-02

Consent Y

Scenario: 1: Medication History - Response | 4 meds - 24 dispenses | Facility discharge | Matilda Doe 

Header

To NPI9999999

From PAYER100

MessageID 200199

RelatesToMessageID 10001

SentTime 2011-01-02T10:15:45

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Approved [Tag included without value]

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023426230

Qualifier TE

Patient 

PatientRelationship 1

Identification

MedicaidNumber FL

MedicareNumber DC123331

Name

LastName DOE

FirstName MATILDA

Gender F

DateOfBirth

Date 1927-09-03

Address

AddressLine1 1358-60 FLORIDA AVE NE

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2025888750

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 5 of 206 Printed: 8/22/2012 10:24 PM
BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName USA BENEFITS

CardholderID 100-19270903-01

ResponsibileParty

LastName DOE

FirstName MATILDA

EffectiveDate

Date 2010-07-02

ExpirationDate

Date 2011-01-02

Coumadin 2 mg tab | Dispensed drug 1 

MedicationDispensed

DrugDescription COUMADIN 2 MG TABLET

DrugCoded

ProductCode 00247152930

ProductCodeQualifier ND

Strength 2

DrugDBCode 855304

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY OR AS DIRECTED BASED ON INR

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-12-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

 © 1st American Systems and Services | www.1asas.com Page 6 of 206 Printed: 8/22/2012 10:24 PM
ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Celebrex 50 mg capsule | Dispensed drug 2 

MedicationDispensed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-12-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

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Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Lipitor 40 mg tablet | Dispensed drug 3 

MedicationDispensed

DrugDescription LIPITOR 40 MG TABLET

DrugCoded

ProductCode 51129142401

ProductCodeQualifier ND

Strength 40

DrugDBCode 617320

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-12-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

 © 1st American Systems and Services | www.1asas.com Page 8 of 206 Printed: 8/22/2012 10:24 PM
CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Caltrate 1500 mg tablet | Dispensed drug 4 

MedicationDispensed

DrugDescription CALTRATE 1500 MG TABLET

DrugCoded

ProductCode 54868484500

ProductCodeQualifier ND

Strength 1500

DrugDBCode 790271

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-12-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

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StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Coumadin 2 mg tab | Dispensed drug 5 

MedicationDispensed

DrugDescription COUMADIN 2 MG TABLET

DrugCoded

ProductCode 00247152930

ProductCodeQualifier ND

Strength 2

DrugDBCode 855304

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY OR AS DIRECTED BASED ON INR

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

 © 1st American Systems and Services | www.1asas.com Page 10 of 206 Printed: 8/22/2012 10:24 PM
LastFillDate

Date 2010-11-13

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Celebrex 50 mg capsule | Dispensed drug 6 

MedicationDispensed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 30

 © 1st American Systems and Services | www.1asas.com Page 11 of 206 Printed: 8/22/2012 10:24 PM
Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-11-13

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Lipitor 40 mg tablet | Dispensed drug 7 

MedicationDispensed

DrugDescription LIPITOR 40 MG TABLET

DrugCoded

ProductCode 51129142401

ProductCodeQualifier ND

Strength 40

DrugDBCode 617320

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

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Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-11-13

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Caltrate 1500 mg tablet | Dispensed drug 8 

MedicationDispensed

DrugDescription CALTRATE 1500 MG TABLET

DrugCoded

ProductCode 54868484500

ProductCodeQualifier ND

Strength 1500

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DrugDBCode 790271

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-11-13

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Coumadin 2 mg tab | Dispensed drug 9 

 © 1st American Systems and Services | www.1asas.com Page 14 of 206 Printed: 8/22/2012 10:24 PM
MedicationDispensed

DrugDescription COUMADIN 2 MG TABLET

DrugCoded

ProductCode 00247152930

ProductCodeQualifier ND

Strength 2

DrugDBCode 855304

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY OR AS DIRECTED BASED ON INR

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-10-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

 © 1st American Systems and Services | www.1asas.com Page 15 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Communication

Number 2026391800

Qualifier FX

Celebrex 50 mg capsule | Dispensed drug 10 

MedicationDispensed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-10-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

 © 1st American Systems and Services | www.1asas.com Page 16 of 206 Printed: 8/22/2012 10:24 PM
City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Lipitor 40 mg tablet | Dispensed drug 11 

MedicationDispensed

DrugDescription LIPITOR 40 MG TABLET

DrugCoded

ProductCode 51129142401

ProductCodeQualifier ND

Strength 40

DrugDBCode 617320

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-10-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

 © 1st American Systems and Services | www.1asas.com Page 17 of 206 Printed: 8/22/2012 10:24 PM
LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Caltrate 1500 mg tablet | Dispensed drug 12 

MedicationDispensed

DrugDescription CALTRATE 1500 MG TABLET

DrugCoded

ProductCode 54868484500

ProductCodeQualifier ND

Strength 1500

DrugDBCode 790271

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-10-14

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

 © 1st American Systems and Services | www.1asas.com Page 18 of 206 Printed: 8/22/2012 10:24 PM
Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Coumadin 2 mg tab | Dispensed drug 13 

MedicationDispensed

DrugDescription COUMADIN 2 MG TABLET

DrugCoded

ProductCode 00247152930

ProductCodeQualifier ND

Strength 2

DrugDBCode 855304

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY OR AS DIRECTED BASED ON INR

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-09-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

 © 1st American Systems and Services | www.1asas.com Page 19 of 206 Printed: 8/22/2012 10:24 PM
Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Celebrex 50 mg capsule | Dispensed drug 14 

MedicationDispensed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-09-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

 © 1st American Systems and Services | www.1asas.com Page 20 of 206 Printed: 8/22/2012 10:24 PM
AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Lipitor 40 mg tablet | Dispensed drug 15 

MedicationDispensed

DrugDescription LIPITOR 40 MG TABLET

DrugCoded

ProductCode 51129142401

ProductCodeQualifier ND

Strength 40

DrugDBCode 617320

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-09-15

 © 1st American Systems and Services | www.1asas.com Page 21 of 206 Printed: 8/22/2012 10:24 PM
Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Caltrate 1500 mg tablet | Dispensed drug 16 

MedicationDispensed

DrugDescription CALTRATE 1500 MG TABLET

DrugCoded

ProductCode 54868484500

ProductCodeQualifier ND

Strength 1500

DrugDBCode 790271

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

 © 1st American Systems and Services | www.1asas.com Page 22 of 206 Printed: 8/22/2012 10:24 PM
Qualifier R

Value 3

WrittenDate

Date 2010-09-15

LastFillDate

Date 2010-09-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Coumadin 2 mg tab | Dispensed drug 17 

MedicationDispensed

DrugDescription COUMADIN 2 MG TABLET

DrugCoded

ProductCode 00247152930

ProductCodeQualifier ND

Strength 2

DrugDBCode 855304

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

 © 1st American Systems and Services | www.1asas.com Page 23 of 206 Printed: 8/22/2012 10:24 PM
CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY OR AS DIRECTED BASED ON INR

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-08-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Celebrex 50 mg capsule | Dispensed drug 18 

MedicationDispensed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

 © 1st American Systems and Services | www.1asas.com Page 24 of 206 Printed: 8/22/2012 10:24 PM
FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-08-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Lipitor 40 mg tablet | Dispensed drug 19 

MedicationDispensed

DrugDescription LIPITOR 40 MG TABLET

 © 1st American Systems and Services | www.1asas.com Page 25 of 206 Printed: 8/22/2012 10:24 PM
DrugCoded

ProductCode 51129142401

ProductCodeQualifier ND

Strength 40

DrugDBCode 617320

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-08-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

 © 1st American Systems and Services | www.1asas.com Page 26 of 206 Printed: 8/22/2012 10:24 PM
Number 2026391800

Qualifier FX

Caltrate 1500 mg tablet | Dispensed drug 20 

MedicationDispensed

DrugDescription CALTRATE 1500 MG TABLET

DrugCoded

ProductCode 54868484500

ProductCodeQualifier ND

Strength 1500

DrugDBCode 790271

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-08-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

 © 1st American Systems and Services | www.1asas.com Page 27 of 206 Printed: 8/22/2012 10:24 PM
ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Coumadin 2 mg tab | Dispensed drug 21 

MedicationDispensed

DrugDescription COUMADIN 2 MG TABLET

DrugCoded

ProductCode 00247152930

ProductCodeQualifier ND

Strength 2

DrugDBCode 855304

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY OR AS DIRECTED BASED ON INR

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-07-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

 © 1st American Systems and Services | www.1asas.com Page 28 of 206 Printed: 8/22/2012 10:24 PM
MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Celebrex 50 mg capsule | Dispensed drug 22 

MedicationDispensed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-07-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

 © 1st American Systems and Services | www.1asas.com Page 29 of 206 Printed: 8/22/2012 10:24 PM
DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Lipitor 40 mg tablet | Dispensed drug 23 

MedicationDispensed

DrugDescription LIPITOR 40 MG TABLET

DrugCoded

ProductCode 51129142401

ProductCodeQualifier ND

Strength 40

DrugDBCode 617320

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-07-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 30 of 206 Printed: 8/22/2012 10:24 PM
Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Caltrate 1500 mg tablet | Dispensed drug 24 

MedicationDispensed

DrugDescription CALTRATE 1500 MG TABLET

DrugCoded

ProductCode 54868484500

ProductCodeQualifier ND

Strength 1500

DrugDBCode 790271

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2010-05-14

LastFillDate

Date 2010-07-15

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

 © 1st American Systems and Services | www.1asas.com Page 31 of 206 Printed: 8/22/2012 10:24 PM
State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Scenario: 1: New Prescription - Coumadin 2 mg tablet | Geriatric w Structured Sig | Facility discharge | Matilda Doe 

Header

To NCPDP03

From NPI9999999

MessageID 3098

SentTime 2011-01-02T10:20:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400098

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

DEANumber DEA300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

 © 1st American Systems and Services | www.1asas.com Page 32 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

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 © 1st American Systems and Services | www.1asas.com Page 33 of 206 Printed: 8/22/2012 10:24 PM
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MultipleSigModifier OR

CodeSystem

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Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

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DoseQuantity 1

DoseFormText TABLET

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DoseFormCode C42998

DoseRangeModifier OR

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CodeSystem

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DoseCompositeIndicator 3

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PayerIdentification

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LastName DOE

FirstName MATILDA

Scenario: 1: New Prescription - MS Contin 30 mg tablet | Controlled substance | Facility discharge | Matilda Doe 

Header

To NCPDP03

From NPI9999999

MessageID 3099

SentTime 2011-03-29T16:27:32

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

 © 1st American Systems and Services | www.1asas.com Page 34 of 206 Printed: 8/22/2012 10:24 PM
Receiver [Tag included without value]

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Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

DEANumber DEA300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

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ZipCode 20009

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Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

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Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

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Communication

Number 2023426230

Qualifier TE

Patient 

DateOfBirth

Date 1927-09-03

Name

LastName DOE

FirstName MATILDA

Gender F

Address

AddressLine1 1358-60 FLORIDA AVE NE

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2025888750

Qualifier TE

MedicationPrescribed

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 © 1st American Systems and Services | www.1asas.com Page 35 of 206 Printed: 8/22/2012 10:24 PM
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CodeListQualifier 38

UnitSourceCode AC

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Refills

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Value 0

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EffectiveDate

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DrugCoverageStatusCode SI

Scenario: 1: New Prescription - Senokot-S 50 mg tablet | Geriatric | Facility discharge | Matilda Doe 

Header

To NCPDP03

From NPI9999999

MessageID 4000

SentTime 2011-03-29T16:28:49

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400100

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NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

DEANumber DEA300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

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Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

 © 1st American Systems and Services | www.1asas.com Page 36 of 206 Printed: 8/22/2012 10:24 PM
StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

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FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

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Communication

Number 2023426230

Qualifier TE

Patient 

DateOfBirth

Date 1927-09-03

Name

LastName DOE

FirstName MATILDA

Gender F

Address

AddressLine1 1358-60 FLORIDA AVE NE

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2025888750

Qualifier TE

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ProductCodeQualifier ND

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DrugDBCode 404196

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FormSourceCode AA

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StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2011-01-02

Scenario: 3: Medication History - Request | 4 meds with 46 dispenses | Hospital discharge | John Doe 

Header

To PAYER200

From NPI4444444

 © 1st American Systems and Services | www.1asas.com Page 37 of 206 Printed: 8/22/2012 10:24 PM
MessageID 101105

SentTime 2011-03-29T16:20:40

Security

Sender

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TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryRequest

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ClinicName ST PAUL GENERAL HOSPITAL

Name

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FirstName JEMMA

Suffix MD

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Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

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Communication

Number 6512661026

Qualifier TE

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName JOHN

Gender M

DateOfBirth

Date 1935-11-07

Address

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City MINNEAPOLIS

State MN

ZipCode 55414

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Communication

Number 6126239176

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName NATIONAL PBM

CardholderID 200-19351107-01

ResponsibileParty

LastName DOE

FirstName JOHN

EffectiveDate

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ExpirationDate

Date 2011-03-29

Consent Y

Scenario: 3: Medication History - Response | 4 meds / 46 dispenses | Hospital discharge | John Doe 

Header

 © 1st American Systems and Services | www.1asas.com Page 38 of 206 Printed: 8/22/2012 10:24 PM
To NPI4444444

From PAYER200

MessageID 300302

RelatesToMessageID 101105

SentTime 2011-03-29T16:55:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

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Prescriber

Identification

NPI NPI4444444

DEANumber DEA252525-JEM444

ClinicName ST PAUL GENERAL HOSPITAL

Name

LastName GRIFFITHS

FirstName JEMMA

Suffix MD

Prefix DR

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName JOHN

Gender M

DateOfBirth

Date 1935-11-07

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

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PayerIdentification

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PayerName NATIONAL PBM

CardholderID 200-19351107-01

ResponsibileParty

LastName DOE

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ExpirationDate

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 © 1st American Systems and Services | www.1asas.com Page 39 of 206 Printed: 8/22/2012 10:24 PM
Lopressor 50mg tab | Dispensed drug 1 

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DrugDBCode 866516

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Date 2010-01-10

LastFillDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

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Address

AddressLine1 1750 HENNEPIN AVE

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Identification

NPI NPI7771234

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Name

LastName FEIST

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Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

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State MN

ZipCode 55404

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Number 6128703000

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 © 1st American Systems and Services | www.1asas.com Page 40 of 206 Printed: 8/22/2012 10:24 PM
DrugDBCode 866516

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Value 30

CodeListQualifier 87

UnitSourceCode AC

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WrittenDate

Date 2010-01-10

LastFillDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI7771234

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Name

LastName FEIST

FirstName LESLIE

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

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Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 3 

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ProductCode 17022014924

ProductCodeQualifier ND

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FormSourceCode AA

FormCode C42998

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Quantity

Value 30

 © 1st American Systems and Services | www.1asas.com Page 41 of 206 Printed: 8/22/2012 10:24 PM
CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

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WrittenDate

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LastFillDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

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State MN

ZipCode 55403

Prescriber

Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

LastName FEIST

FirstName LESLIE

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

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ZipCode 55404

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Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 4 

MedicationDispensed

DrugDescription LOPRESSOR 50 MG TABLET

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ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

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CodeListQualifier 87

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WrittenDate

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LastFillDate

 © 1st American Systems and Services | www.1asas.com Page 42 of 206 Printed: 8/22/2012 10:24 PM
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Pharmacy

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NCPDPID NCPDP01

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StoreName WALKER PHARMACY

Address

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Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

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AddressLine1 2400 THIRD AVENUE SO

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Communication

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Lopressor 50mg tab | Dispensed drug 5 

MedicationDispensed

DrugDescription LOPRESSOR 50 MG TABLET

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ProductCode 17022014924

ProductCodeQualifier ND

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DrugDBCode 866516

DrugDBCodeQualifier SBD

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WrittenDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

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 © 1st American Systems and Services | www.1asas.com Page 43 of 206 Printed: 8/22/2012 10:24 PM
City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI7771234

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AddressLine1 2400 THIRD AVENUE SO

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ZipCode 55404

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Lopressor 50mg tab | Dispensed drug 6 

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ProductCode 17022014924

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WrittenDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

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Prescriber

Identification

NPI NPI7771234

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 © 1st American Systems and Services | www.1asas.com Page 44 of 206 Printed: 8/22/2012 10:24 PM
LastName FEIST

FirstName LESLIE

Suffix MD

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Address

AddressLine1 2400 THIRD AVENUE SO

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City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 7 

MedicationDispensed

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ProductCode 17022014924

ProductCodeQualifier ND

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DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

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WrittenDate

Date 2010-06-10

LastFillDate

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Pharmacy

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NCPDPID NCPDP01

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StoreName WALKER PHARMACY

Address

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Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

LastName FEIST

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Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

 © 1st American Systems and Services | www.1asas.com Page 45 of 206 Printed: 8/22/2012 10:24 PM
State MN

ZipCode 55404

CommunicationNumbers

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Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 8 

MedicationDispensed

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ProductCode 17022014924

ProductCodeQualifier ND

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CodeListQualifier 87

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WrittenDate

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LastFillDate

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Pharmacy

Identification

NCPDPID NCPDP01

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Address

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ZipCode 55403

Prescriber

Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

LastName FEIST

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Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

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ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 9 

 © 1st American Systems and Services | www.1asas.com Page 46 of 206 Printed: 8/22/2012 10:24 PM
MedicationDispensed

DrugDescription LOPRESSOR 50 MG TABLET

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ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

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StrengthSourceCode AB

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Quantity

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CodeListQualifier 87

UnitSourceCode AC

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DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

LastName FEIST

FirstName LESLIE

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

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ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 10 

MedicationDispensed

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ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

 © 1st American Systems and Services | www.1asas.com Page 47 of 206 Printed: 8/22/2012 10:24 PM
FormSourceCode AA

FormCode C42998

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WrittenDate

Date 2010-12-10

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

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State MN

ZipCode 55403

Prescriber

Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

LastName FEIST

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Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 11 

MedicationDispensed

DrugDescription LOPRESSOR 50 MG TABLET

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ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

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Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

 © 1st American Systems and Services | www.1asas.com Page 48 of 206 Printed: 8/22/2012 10:24 PM
PotencyUnitCode C48542

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Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-12-10

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

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State MN

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Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

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Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Lopressor 50mg tab | Dispensed drug 12 

MedicationDispensed

DrugDescription LOPRESSOR 50 MG TABLET

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DrugDBCodeQualifier SBD

FormSourceCode AA

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UnitSourceCode AC

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WrittenDate

Date 2011-03-15

LastFillDate

Date 2011-03-15

Pharmacy

 © 1st American Systems and Services | www.1asas.com Page 49 of 206 Printed: 8/22/2012 10:24 PM
Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

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State MN

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Prescriber

Identification

NPI NPI7771234

ClinicName MINNEAPOLIS

Name

LastName FEIST

FirstName LESLIE

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 13 

MedicationDispensed

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ProductCodeQualifier ND

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DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

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Quantity

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CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

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WrittenDate

Date 2010-06-10

LastFillDate

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

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State MN

 © 1st American Systems and Services | www.1asas.com Page 50 of 206 Printed: 8/22/2012 10:24 PM
ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

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Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 14 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-07-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

 © 1st American Systems and Services | www.1asas.com Page 51 of 206 Printed: 8/22/2012 10:24 PM
Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 15 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-08-09

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

 © 1st American Systems and Services | www.1asas.com Page 52 of 206 Printed: 8/22/2012 10:24 PM
CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 16 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-09-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 17 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

 © 1st American Systems and Services | www.1asas.com Page 53 of 206 Printed: 8/22/2012 10:24 PM
DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-10-12

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 18 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

 © 1st American Systems and Services | www.1asas.com Page 54 of 206 Printed: 8/22/2012 10:24 PM
StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-11-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 19 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

 © 1st American Systems and Services | www.1asas.com Page 55 of 206 Printed: 8/22/2012 10:24 PM
Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-12-11

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 20 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2011-01-12

Pharmacy

Identification

NCPDPID NCPDP01

 © 1st American Systems and Services | www.1asas.com Page 56 of 206 Printed: 8/22/2012 10:24 PM
NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 21 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2011-02-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

 © 1st American Systems and Services | www.1asas.com Page 57 of 206 Printed: 8/22/2012 10:24 PM
Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Crestor 10 mg tab | Dispensed drug 22 

MedicationDispensed

DrugDescription CRESTOR 10 MG TABLET

DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2011-03-15

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

 © 1st American Systems and Services | www.1asas.com Page 58 of 206 Printed: 8/22/2012 10:24 PM
Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 23 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2009-12-14

LastFillDate

Date 2010-04-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

 © 1st American Systems and Services | www.1asas.com Page 59 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Vasotec 5 mg tab | Dispensed drug 24 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2009-12-14

LastFillDate

Date 2010-05-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 25 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

 © 1st American Systems and Services | www.1asas.com Page 60 of 206 Printed: 8/22/2012 10:24 PM
DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-06-11

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 26 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

 © 1st American Systems and Services | www.1asas.com Page 61 of 206 Printed: 8/22/2012 10:24 PM
UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-07-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 27 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-08-09

Pharmacy

 © 1st American Systems and Services | www.1asas.com Page 62 of 206 Printed: 8/22/2012 10:24 PM
Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 28 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-09-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

 © 1st American Systems and Services | www.1asas.com Page 63 of 206 Printed: 8/22/2012 10:24 PM
Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 29 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-10-12

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

 © 1st American Systems and Services | www.1asas.com Page 64 of 206 Printed: 8/22/2012 10:24 PM
Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 30 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-11-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 65 of 206 Printed: 8/22/2012 10:24 PM
Vasotec 5 mg tab | Dispensed drug 31 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2010-12-11

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 32 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

 © 1st American Systems and Services | www.1asas.com Page 66 of 206 Printed: 8/22/2012 10:24 PM
DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2011-01-12

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 33 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

 © 1st American Systems and Services | www.1asas.com Page 67 of 206 Printed: 8/22/2012 10:24 PM
PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2011-02-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Vasotec 5 mg tab | Dispensed drug 34 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-06-10

LastFillDate

Date 2011-03-15

Pharmacy

Identification

 © 1st American Systems and Services | www.1asas.com Page 68 of 206 Printed: 8/22/2012 10:24 PM
NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI1010101

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Advair inhaler | Dispensed drug 35 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-03-15

LastFillDate

Date 2010-04-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

 © 1st American Systems and Services | www.1asas.com Page 69 of 206 Printed: 8/22/2012 10:24 PM
MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 36 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-03-15

LastFillDate

Date 2010-05-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 70 of 206 Printed: 8/22/2012 10:24 PM
Advair inhaler | Dispensed drug 37 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-03-15

LastFillDate

Date 2010-06-11

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 38 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

 © 1st American Systems and Services | www.1asas.com Page 71 of 206 Printed: 8/22/2012 10:24 PM
PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-03-15

LastFillDate

Date 2010-07-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 39 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-08-09

LastFillDate

Date 2010-08-09

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

 © 1st American Systems and Services | www.1asas.com Page 72 of 206 Printed: 8/22/2012 10:24 PM
City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 40 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-08-09

LastFillDate

Date 2010-09-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

 © 1st American Systems and Services | www.1asas.com Page 73 of 206 Printed: 8/22/2012 10:24 PM
Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 41 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-08-09

LastFillDate

Date 2010-10-12

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 42 

MedicationDispensed

 © 1st American Systems and Services | www.1asas.com Page 74 of 206 Printed: 8/22/2012 10:24 PM
DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-11-09

LastFillDate

Date 2010-11-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 43 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

 © 1st American Systems and Services | www.1asas.com Page 75 of 206 Printed: 8/22/2012 10:24 PM
Date 2010-11-09

LastFillDate

Date 2010-12-11

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 44 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-11-09

LastFillDate

Date 2011-01-12

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

 © 1st American Systems and Services | www.1asas.com Page 76 of 206 Printed: 8/22/2012 10:24 PM
Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 45 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2010-11-09

LastFillDate

Date 2011-02-10

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI8888999

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

 © 1st American Systems and Services | www.1asas.com Page 77 of 206 Printed: 8/22/2012 10:24 PM
City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Advair inhaler | Dispensed drug 46 

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

DrugDBCode 896243

DrugDBCodeQualifier SBD

Quantity

Value 2

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

WrittenDate

Date 2011-03-15

LastFillDate

Date 2011-03-15

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

Prescriber

Identification

NPI NPI3333333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Scenario: 3: New Prescription - Vasotec 5 mg tablet | Resident w/supervisor | Hospital discharge | John Doe 

Header

To NCPDP01

From NPI4444444

MessageID 101106

 © 1st American Systems and Services | www.1asas.com Page 78 of 206 Printed: 8/22/2012 10:24 PM
SentTime 2011-03-29T16:25:02

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORDSPG1001

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI4444444

DEANumber DEA252525-JEM444

ClinicName ST PAUL GENERAL HOSPITAL

Name

LastName GRIFFITHS

FirstName JEMMA

Suffix MD

Prefix DR

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

PrescriberAgent

LastName CHERRY

FirstName DON

Suffix RN

Supervisor

Identification

NPI NPI5435435

Name

LastName BLACKWELL

FirstName ED

Prefix DR

ClinicName ST PAUL GENERAL HOSPITAL

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

 © 1st American Systems and Services | www.1asas.com Page 79 of 206 Printed: 8/22/2012 10:24 PM
CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2011-03-29

Scenario: 3: New Prescription - Lopressor 50 mg tab | Resident w/supervisor | Hospital discharge | John Doe 

Header

To NCPDP01

From NPI4444444

MessageID 101107

SentTime 2011-03-29T16:27:32

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORDSPG1002

Body

NewRx

Pharmacy

Identification

 © 1st American Systems and Services | www.1asas.com Page 80 of 206 Printed: 8/22/2012 10:24 PM
NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI4444444

DEANumber DEA252525-JEM444

ClinicName ST PAUL GENERAL HOSPITAL

Name

LastName GRIFFITHS

FirstName JEMMA

Suffix MD

Prefix DR

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

PrescriberAgent

LastName CHERRY

FirstName DON

Suffix RN

Supervisor

Identification

NPI NPI5435435

Name

LastName BLACKWELL

FirstName ED

Prefix DR

ClinicName ST PAUL GENERAL HOSPITAL

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

 © 1st American Systems and Services | www.1asas.com Page 81 of 206 Printed: 8/22/2012 10:24 PM
Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription LOPRESSOR 50 MG TABLET

DrugCoded

ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-03-29

Scenario: 3: New Prescription - Crestor 10 mg tab | Resident w/supervisor | Hospital discharge | John Doe 

Header

To NCPDP01

From NPI4444444

MessageID 101108

SentTime 2011-03-29T16:28:49

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORDSPG1003

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

 © 1st American Systems and Services | www.1asas.com Page 82 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI4444444

DEANumber DEA252525-JEM444

ClinicName ST PAUL GENERAL HOSPITAL

Name

LastName GRIFFITHS

FirstName JEMMA

Suffix MD

Prefix DR

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

PrescriberAgent

LastName CHERRY

FirstName DON

Suffix RN

Supervisor

Identification

NPI NPI5435435

Name

LastName BLACKWELL

FirstName ED

Prefix DR

ClinicName ST PAUL GENERAL HOSPITAL

Address

AddressLine1 50 W KELLOGG BLVD

City ST PAUL

State MN

ZipCode 55102

CommunicationNumbers

Communication

Number 6512661026

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription CRESTOR 10 MG TABLET

 © 1st American Systems and Services | www.1asas.com Page 83 of 206 Printed: 8/22/2012 10:24 PM
DrugCoded

ProductCode 49999087390

ProductCodeQualifier ND

Strength 10

DrugDBCode 859749

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2011-03-29

Scenario: 4: Refill Request - Lopressor 50 mg tab | Approved | Ambulatory | John Doe 

Header

To NPI7771234

From NCPDP01

MessageID 108001

SentTime 2011-04-27T14:30:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARMSPG1002

PrescriberOrderNumber ORDSPG1002

Body

RefillRequest

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI7771234

DEANumber DEA777123

ClinicName MINNEAPOLIS CLINIC

Name

 © 1st American Systems and Services | www.1asas.com Page 84 of 206 Printed: 8/22/2012 10:24 PM
LastName FEIST

FirstName LESLIE

Suffix MD

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription LOPRESSOR 50 MG TABLET

DrugCoded

ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier P

Value 2

WrittenDate

Date 2011-03-29

MedicationDispensed

DrugDescription LOPRESSOR 50 MG TABLET

DrugCoded

ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

 © 1st American Systems and Services | www.1asas.com Page 85 of 206 Printed: 8/22/2012 10:24 PM
FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier P

Value 3

LastFillDate

Date 2011-03-29

Scenario: 4: Refill Response - Lopressor 50 mg tab | Approved response | Ambulatory | John Doe 

Header

To NCPDP01

From NPI7771234

MessageID 1007

RelatesToMessageID 108001

SentTime 2011-04-27T15:20:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARMSPG1002

PrescriberOrderNumber ORD00100101

Body

RefillResponse

Response

Approved [Tag included without value]

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI7771234

DEANumber DEA777123

ClinicName MINNEAPOLIS CLINIC

Name

LastName FEIST

FirstName LESLIE

Suffix MD

Address

AddressLine1 2400 THIRD AVENUE SO

 © 1st American Systems and Services | www.1asas.com Page 86 of 206 Printed: 8/22/2012 10:24 PM
AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription LOPRESSOR 50 MG TABLET

DrugCoded

ProductCode 17022014924

ProductCodeQualifier ND

Strength 50

DrugDBCode 866516

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier A

Value 3

WrittenDate

Date 2011-04-27

Scenario: 4: Refill Request - Advair inhaler | Denied | Ambulatory | John Doe 

Header

To NPI8888999

From NCPDP01

MessageID 108002

SentTime 2011-04-27T14:31:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM0000099

 © 1st American Systems and Services | www.1asas.com Page 87 of 206 Printed: 8/22/2012 10:24 PM
PrescriberOrderNumber ORD0000099

Body

RefillRequest

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI8888999

DEANumber DEA888899

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

 © 1st American Systems and Services | www.1asas.com Page 88 of 206 Printed: 8/22/2012 10:24 PM
Strength 0.115

DrugDBCode 896243

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C91148

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 2

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C62275

DaysSupply 30

Directions TAKE TWO PUFFS TWICE DAILY

Refills

Qualifier P

Value 3

WrittenDate

Date 2011-03-15

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

Strength 0.115

DrugDBCode 896243

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C91148

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 2

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C62275

DaysSupply 30

Directions TAKE TWO PUFFS TWICE DAILY

Refills

Qualifier P

Value 3

LastFillDate

Date 2011-03-15

Scenario: 4: Refill Response - Advair inhaler | Denied response | Ambulatory | John Doe 

Header

To NCPDP01

From NPI8888999

MessageID 1008

RelatesToMessageID 108002

SentTime 2011-04-27T15:20:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM0000099

PrescriberOrderNumber ORD0000099

Body

RefillResponse

Response

 © 1st American Systems and Services | www.1asas.com Page 89 of 206 Printed: 8/22/2012 10:24 PM
Denied

DenialReasonCode AM

DenialReason PATIENT VISIT NEEDED

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI8888999

DEANumber DEA888899

ClinicName MINNEAPOLIS CLINIC

Name

LastName FERGUSON

FirstName STACY

MiddleName ANN

Suffix MD

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

 © 1st American Systems and Services | www.1asas.com Page 90 of 206 Printed: 8/22/2012 10:24 PM
Strength 0.115

DrugDBCode 896243

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C91148

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 0

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C62275

Directions TAKE TWO PUFFS TWICE DAILY

Refills

Qualifier A

Value 0

WrittenDate

Date 2011-04-27

Scenario: 5: Refill Request - Advair inhaler | Approved | Ambulatory | John Doe 

Header

To NPI3333333

From NCPDP01

MessageID 108003

SentTime 2011-04-27T16:35:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM0000099

PrescriberOrderNumber ORD0000099

Body

RefillRequest

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI3333333

DEANumber DEA333333

StateLicenseNumber LIC33333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

 © 1st American Systems and Services | www.1asas.com Page 91 of 206 Printed: 8/22/2012 10:24 PM
Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

Strength 0.115

DrugDBCode 896243

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C91148

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 2

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C62275

DaysSupply 30

Directions TAKE TWO PUFFS TWICE DAILY

Refills

Qualifier P

Value 3

WrittenDate

Date 2011-03-15

MedicationDispensed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

Strength 0.115

DrugDBCode 896243

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C91148

StrengthSourceCode AB

 © 1st American Systems and Services | www.1asas.com Page 92 of 206 Printed: 8/22/2012 10:24 PM
StrengthCode C28253

Quantity

Value 2

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C62275

DaysSupply 30

Directions TAKE TWO PUFFS TWICE DAILY

Refills

Qualifier P

Value 3

LastFillDate

Date 2011-03-15

Scenario: 5: Refill Response - Advair inhaler | Approved response | Ambulatory | John Doe 

Header

To NCPDP01

From NPI3333333

MessageID 1007

RelatesToMessageID 108003

SentTime 2011-04-27T17:05:14

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM0000099

PrescriberOrderNumber ORD00100102

Body

RefillResponse

Response

Approved [Tag included without value]

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI3333333

DEANumber DEA333333

StateLicenseNumber LIC33333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Suffix MD

Prefix DR

Address

 © 1st American Systems and Services | www.1asas.com Page 93 of 206 Printed: 8/22/2012 10:24 PM
AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Patient 

DateOfBirth

Date 1935-11-07

Name

LastName DOE

FirstName JOHN

Gender M

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription ADVAIR HPA 115/21 60 ACTUAT

DrugCoded

ProductCode 00173071661

ProductCodeQualifier ND

Strength 0.115

DrugDBCode 896243

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C91148

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 2

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C62275

DaysSupply 30

Directions TAKE TWO PUFFS TWICE DAILY

Refills

Qualifier A

Value 3

WrittenDate

Date 2011-04-27

Scenario: 6: Medication History - Request | 2 medications found | Emergency Dept | Jane Doe 

Header

To PAYER300

From NPI2020202

MessageID 3001

SentTime 2011-03-22T22:01:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

 © 1st American Systems and Services | www.1asas.com Page 94 of 206 Printed: 8/22/2012 10:24 PM
Body

RxHistoryRequest

Prescriber

Identification

NPI NPI2020202

DEANumber DEA202020-BC202

ClinicName CORCORAN HOSPITAL EMERGENCY DEPT

Name

LastName CAMPBELL

FirstName BEK

MiddleName DAVID

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName JANE

Gender F

DateOfBirth

Date 1985-11-30

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER300

PayerName PHARMA BENEFITS

CardholderID 100-19681102

ResponsibileParty

LastName DOE

FirstName JANE

EffectiveDate

Date 2010-03-22

ExpirationDate

Date 2011-03-22

Consent Y

Scenario: 6: Medication History - Response | 2 medications found | Emergency Dept | Jane Doe 

Header

To NPI2020202

From PAYER300

MessageID 400401

RelatesToMessageID 3001

SentTime 2011-03-22T22:01:23

 © 1st American Systems and Services | www.1asas.com Page 95 of 206 Printed: 8/22/2012 10:24 PM
Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Approved [Tag included without value]

Prescriber

Identification

NPI NPI2020202

DEANumber DEA202020-BC202

ClinicName CORCORAN HOSPITAL EMERGENCY DEPT

Name

LastName CAMPBELL

FirstName BEK

MiddleName DAVID

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName JANE

Gender F

DateOfBirth

Date 1985-11-30

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER300

PayerName PHARMA BENEFITS

CardholderID 100-19681102

ResponsibileParty

LastName DOE

FirstName JANE

EffectiveDate

Date 2010-03-22

ExpirationDate

Date 2011-03-22

Triphasil-21 | Dispensed drug 1 

MedicationDispensed

 © 1st American Systems and Services | www.1asas.com Page 96 of 206 Printed: 8/22/2012 10:24 PM
DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-04-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 2 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

 © 1st American Systems and Services | www.1asas.com Page 97 of 206 Printed: 8/22/2012 10:24 PM
Date 2010-04-01

LastFillDate

Date 2010-05-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 3 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-06-02

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

 © 1st American Systems and Services | www.1asas.com Page 98 of 206 Printed: 8/22/2012 10:24 PM
NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 4 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-06-30

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

 © 1st American Systems and Services | www.1asas.com Page 99 of 206 Printed: 8/22/2012 10:24 PM
Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 5 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-08-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 6 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

 © 1st American Systems and Services | www.1asas.com Page 100 of 206 Printed: 8/22/2012 10:24 PM
CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-09-02

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 7 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-10-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

 © 1st American Systems and Services | www.1asas.com Page 101 of 206 Printed: 8/22/2012 10:24 PM
AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 8 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-11-03

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

 © 1st American Systems and Services | www.1asas.com Page 102 of 206 Printed: 8/22/2012 10:24 PM
Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 9 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2010-12-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 10 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

 © 1st American Systems and Services | www.1asas.com Page 103 of 206 Printed: 8/22/2012 10:24 PM
ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2011-01-02

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 11 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

 © 1st American Systems and Services | www.1asas.com Page 104 of 206 Printed: 8/22/2012 10:24 PM
Date 2011-02-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Triphasil-21 | Dispensed drug 12 

MedicationDispensed

DrugDescription TRIPHASIL-21

DrugCoded

ProductCode 00008253505

ProductCodeQualifier ND

DrugDBCode 748867

DrugDBCodeQualifier BPK

Quantity

Value 1

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48520

Directions TAKE ONE TABLET DAILY AS DIRECTED FOR 3 WEEKS. 

DISCONTINUE FOR 1 WEEK. REPEAT

WrittenDate

Date 2010-04-01

LastFillDate

Date 2011-03-03

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

 © 1st American Systems and Services | www.1asas.com Page 105 of 206 Printed: 8/22/2012 10:24 PM
Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Multigen Plus | Dispensed drug 13 

MedicationDispensed

DrugDescription MULTIGEN PLUS

DrugCoded

ProductCode 10267349400

ProductCodeQualifier ND

DrugDBCode 802748

DrugDBCodeQualifier SBD

Quantity

Value 90

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-09-07

LastFillDate

Date 2010-09-08

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

 © 1st American Systems and Services | www.1asas.com Page 106 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Multigen Plus | Dispensed drug 14 

MedicationDispensed

DrugDescription MULTIGEN PLUS

DrugCoded

ProductCode 10267349400

ProductCodeQualifier ND

DrugDBCode 802748

DrugDBCodeQualifier SBD

Quantity

Value 90

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-09-07

LastFillDate

Date 2010-12-01

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Multigen Plus | Dispensed drug 15 

MedicationDispensed

DrugDescription MULTIGEN PLUS

DrugCoded

ProductCode 10267349400

ProductCodeQualifier ND

DrugDBCode 802748

DrugDBCodeQualifier SBD

Quantity

Value 90

CodeListQualifier 87

UnitSourceCode AC

 © 1st American Systems and Services | www.1asas.com Page 107 of 206 Printed: 8/22/2012 10:24 PM
PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

WrittenDate

Date 2010-09-07

LastFillDate

Date 2011-03-03

Pharmacy

Identification

NCPDPID NCPDP03

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI8888888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Suffix MD

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Scenario: 6: New Prescription - Deltasone tapered dose | Structured SIG | Emergency Dept | Jane Doe 

Header

To NCPDP03

From NPI2020202

MessageID 3002

SentTime 2011-03-22T22:30:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00300101

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

 © 1st American Systems and Services | www.1asas.com Page 108 of 206 Printed: 8/22/2012 10:24 PM
Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI2020202

DEANumber DEA202020-BC202

ClinicName CORCORAN HOSPITAL EMERGENCY DEPT

Name

LastName CAMPBELL

FirstName BEK

MiddleName DAVID

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Supervisor

Identification

NPI NPI4321321

DEANumber DEA432121

Name

LastName LAWRIE

FirstName MARIE

MiddleName MCDONALD MCLAUGHLIN

Prefix MD

ClinicName CORCORAN HOSPITAL EMERGENCY DEPT

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1985-11-30

Name

LastName DOE

FirstName JANE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

 © 1st American Systems and Services | www.1asas.com Page 109 of 206 Printed: 8/22/2012 10:24 PM
Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription DELTASONE 10 MG TABLET

DrugCoded

ProductCode 66267041230

ProductCodeQualifier ND

Strength 10

DrugDBCode 206988

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 12

Directions TAKE 4 TABLETS DAILY FOR 3 DAYS. THEN 3 TABLETS DAILY 

FOR THREE DAYS. THEN 2 TABLETS DAILY FOR 3 DAYS. THEN 1 

TABLET DAILY FOR 3 DAYS - STOP

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-03-22

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 1

MultipleSigModifier THEN

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 2

SigFreeText TAKE 4 TABLETS DAILY FOR 3 DAYS. THEN 3 TABLETS DAILY 

FOR THREE DAYS. THEN 2 TABLETS DAILY FOR 3 DAYS. THEN 1 

TABLET DAILY FOR 3 DAYS - STOP

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 4

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Duration

DurationNumericValue 3

DurationText DAY

 © 1st American Systems and Services | www.1asas.com Page 110 of 206 Printed: 8/22/2012 10:24 PM
DurationTextCodeQualifier 1

DurationTextCode 258703001

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 2

MultipleSigModifier THEN

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 2

SigFreeText TAKE 4 TABLETS DAILY FOR 3 DAYS. THEN 3 TABLETS DAILY 

FOR THREE DAYS. THEN 2 TABLETS DAILY FOR 3 DAYS. THEN 1 

TABLET DAILY FOR 3 DAYS - STOP

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 3

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Duration

DurationNumericValue 3

DurationText DAY

DurationTextCodeQualifier 1

DurationTextCode 258703001

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 3

MultipleSigModifier THEN

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 2

SigFreeText TAKE 4 TABLETS DAILY FOR 3 DAYS. THEN 3 TABLETS DAILY 

FOR THREE DAYS. THEN 2 TABLETS DAILY FOR 3 DAYS. THEN 1 

TABLET DAILY FOR 3 DAYS - STOP

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 2

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

 © 1st American Systems and Services | www.1asas.com Page 111 of 206 Printed: 8/22/2012 10:24 PM
Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Duration

DurationNumericValue 3

DurationText DAY

DurationTextCodeQualifier 1

DurationTextCode 258703001

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 4

MultipleSigModifier THEN

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 2

SigFreeText TAKE 4 TABLETS DAILY FOR 3 DAYS. THEN 3 TABLETS DAILY 

FOR THREE DAYS. THEN 2 TABLETS DAILY FOR 3 DAYS. THEN 1 

TABLET DAILY FOR 3 DAYS - STOP

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 1

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Duration

DurationNumericValue 3

DurationText DAY

DurationTextCodeQualifier 1

DurationTextCode 258703001

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 5

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 2

SigFreeText TAKE 4 TABLETS DAILY FOR 3 DAYS. THEN 3 TABLETS DAILY 

FOR THREE DAYS. THEN 2 TABLETS DAILY FOR 3 DAYS. THEN 1 

TABLET DAILY FOR 3 DAYS - STOP

Dose

DoseCompositeIndicator 1

Stop 

StopIndicator Y

Scenario: 7: New Prescription - Allegra 60 mg tab | Simple dose | Ambulatory | Jane Doe 

 © 1st American Systems and Services | www.1asas.com Page 112 of 206 Printed: 8/22/2012 10:24 PM
Header

To NCPDP03

From NPI1010101

MessageID 4001

SentTime 2011-03-24T14:05:00

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400101

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1985-11-30

Name

LastName DOE

FirstName JANE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

 © 1st American Systems and Services | www.1asas.com Page 113 of 206 Printed: 8/22/2012 10:24 PM
City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription ALLEGRA 60 MG TABLET

DrugCoded

ProductCode 00247197020

ProductCodeQualifier ND

Strength 60

DrugDBCode 997502

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 14

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 7

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-03-24

Scenario: 7: New Prescription - EpiPen Injection | Take if needed | Ambulatory | Jane Doe 

Header

To NCPDP03

From NPI1010101

MessageID 4002

SentTime 2011-03-24T14:08:40

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400102

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

 © 1st American Systems and Services | www.1asas.com Page 114 of 206 Printed: 8/22/2012 10:24 PM
Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1985-11-30

Name

LastName DOE

FirstName JANE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription EPIPEN INJECTION

DrugCoded

ProductCode 11704050001

ProductCodeQualifier ND

Strength 5

DrugDBCode 727347

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42946

StrengthSourceCode AB

StrengthCode C91131

Quantity

Value 1

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48540

Directions INJECT FULL SYRINGE IF NEEDED

Refills

Qualifier R

Value 0

WrittenDate

 © 1st American Systems and Services | www.1asas.com Page 115 of 206 Printed: 8/22/2012 10:24 PM
Date 2011-03-24

Scenario: 8: Change Request - Allegra 60 mg tab | Prescribed med | Ambulatory | Jane Doe 

Header

To NPI1010101

From NCPDP03

MessageID 8015

RelatesToMessageID 4001

SentTime 2011-03-26T09:45:11

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00400101

PrescriberOrderNumber ORD00400101

Body

RxChangeRequest

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1985-11-30

Name

 © 1st American Systems and Services | www.1asas.com Page 116 of 206 Printed: 8/22/2012 10:24 PM
LastName DOE

FirstName JANE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription ALLEGRA 60 MG TABLET

DrugCoded

ProductCode 00247197020

ProductCodeQualifier ND

Strength 60

DrugDBCode 997502

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 14

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 7

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-03-24

LastFillDate

Date 2011-03-24

Zyrtec 10 mg tab | Requested med 

MedicationRequested

DrugDescription ZYRTEC 10 MG TABLET

DrugCoded

ProductCode 00247147907

ProductCodeQualifier ND

Strength 10

DrugDBCode 1020026

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 7

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 7

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 0

 © 1st American Systems and Services | www.1asas.com Page 117 of 206 Printed: 8/22/2012 10:24 PM
Scenario: 8: Change Response - Zyrtec 10 mg tab | Approved | Ambulatory | Jane Doe 

Header

To NCPDP03

From NPI1010101

MessageID 4003

RelatesToMessageID 8015

SentTime 2011-03-26T10:43:35

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00400101

PrescriberOrderNumber ORD00400103

Body

RxChangeResponse

Response

Approved [Tag included without value]

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1985-11-30

 © 1st American Systems and Services | www.1asas.com Page 118 of 206 Printed: 8/22/2012 10:24 PM
Name

LastName DOE

FirstName JANE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription ZYRTEC 10 MG TABLET

DrugCoded

ProductCode 00247147907

ProductCodeQualifier ND

Strength 10

DrugDBCode 1020026

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 7

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 7

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-03-26

Scenario: 9: Medication History - Request | No medications found | Ambulatory | James Doe 

Header

To Qualifier="P" PAYER100

From Qualifier="D" NPI1111111

MessageID 1001

SentTime 2011-01-15T10:30:30

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryRequest

Prescriber

Identification

NPI NPI1111111

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

 © 1st American Systems and Services | www.1asas.com Page 119 of 206 Printed: 8/22/2012 10:24 PM
AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName JAMES

Gender M

DateOfBirth

Date 1968-11-01

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER100

PayerName USA BENEFITS

CardholderID 100-19681101

ResponsibileParty

LastName DOE

FirstName JAMES

EffectiveDate

Date 2010-01-15

ExpirationDate

Date 2011-01-15

Consent Y

Scenario: 9: Medication History - Response | No medications found | Ambulatory | James Doe 

Header

To Qualifier="P" NPI1111111

From Qualifier="D" PAYER100

MessageID 200200

RelatesToMessageID 1001

SentTime 2011-01-15T10:30:34

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Approved [Tag included without value]

Prescriber

Identification

 © 1st American Systems and Services | www.1asas.com Page 120 of 206 Printed: 8/22/2012 10:24 PM
NPI NPI1111111

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName JAMES

Gender M

DateOfBirth

Date 1968-11-01

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER100

PayerName USA BENEFITS

CardholderID 100-19681101

ResponsibileParty

LastName DOE

FirstName JAMES

EffectiveDate

Date 2010-01-15

ExpirationDate

Date 2011-01-15

Scenario: 9: New Prescription - Diclofenac 75 mg tab | Simple dose | Ambulatory | James Doe 

Header

To Qualifier="P" NCPDP01

From Qualifier="D" NPI1111111

MessageID 1002

SentTime 2011-01-15T10:40:09

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

 © 1st American Systems and Services | www.1asas.com Page 121 of 206 Printed: 8/22/2012 10:24 PM
PrescriberOrderNumber ORD00100103

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI1111111

DEANumber DEA111111

StateLicenseNumber LIC11111

ClinicName MINNEAPOLIS CLINIC

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1968-11-01

Name

LastName DOE

FirstName JAMES

Gender M

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

MedicationPrescribed

DrugDescription DICLOFENAC SODIUM 75MG ENTERIC COATED TABLET

DrugCoded

ProductCode 00054422225

ProductCodeQualifier ND

Strength 75

DrugDBCode 855926

DrugDBCodeQualifier SCD

FormSourceCode AA

 © 1st American Systems and Services | www.1asas.com Page 122 of 206 Printed: 8/22/2012 10:24 PM
FormCode C42758

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 28

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 28

Directions TAKE ONE TABLET TWICE DAILY FOR 14 DAYS

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-01-15

Scenario: 10: Medication History - Request | 1 medication found | Ambulatory | Mary Doe 

Header

To Qualifier="P" PAYER100

From Qualifier="D" NPI1111111

MessageID 1003

SentTime 2011-01-20T11:01:00

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryRequest

Prescriber

Identification

NPI NPI1111111

DEANumber DEA111111

StateLicenseNumber LIC11111

ClinicName MINNEAPOLIS CLINIC

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

PatientRelationship 2

Name

LastName DOE

FirstName MARY

Gender F

DateOfBirth

 © 1st American Systems and Services | www.1asas.com Page 123 of 206 Printed: 8/22/2012 10:24 PM
Date 1956-10-14

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER100

PayerName USA BENEFITS

CardholderID 100-19681102

ResponsibileParty

LastName DOE

FirstName MARY

EffectiveDate

Date 2010-01-20

ExpirationDate

Date 2011-01-20

Consent Y

Scenario: 10: Medication History - Response | 1 medication found | Ambulatory | Mary Doe 

Header

To Qualifier="P" NPI1111111

From Qualifier="D" PAYER100

MessageID 200201

RelatesToMessageID 1003

SentTime 2011-01-20T11:01:04

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Approved [Tag included without value]

Prescriber

Identification

NPI NPI1111111

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

 © 1st American Systems and Services | www.1asas.com Page 124 of 206 Printed: 8/22/2012 10:24 PM
Qualifier FX

Patient 

PatientRelationship 2

Name

LastName DOE

FirstName MARY

Gender F

DateOfBirth

Date 1956-10-14

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER100

PayerName USA BENEFITS

CardholderID 100-19681102

ResponsibileParty

LastName DOE

FirstName MARY

EffectiveDate

Date 2010-01-20

ExpirationDate

Date 2011-01-20

Diclofenac 75 mg tab | Dispensed drug 

MedicationDispensed

DrugDescription DICLOFENAC SODIUM 75MG ENTERIC COATED TABLET

DrugCoded

ProductCode 00054422225

ProductCodeQualifier ND

Quantity

Value 28

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

Directions TAKE ONE TABLET TWO TIMES A DAY

WrittenDate

Date 2010-12-30

LastFillDate

Date 2010-12-30

Pharmacy

Identification

NCPDPID NCPDP87

StoreName USA PHARMACY #24

Address

AddressLine1 100 1ST ST

City PHOENIX

State AZ

ZipCode 85001

Prescriber

Identification

NPI NPI3134158

ClinicName PHOENIX GENERAL HOSPITAL EMERGENCY

Name

LastName GILBERTSON

 © 1st American Systems and Services | www.1asas.com Page 125 of 206 Printed: 8/22/2012 10:24 PM
FirstName LYNNE

Suffix MD

CommunicationNumbers

Communication

Number 6025551212

Qualifier TE

Scenario: 10: New Prescription - Vaseretic 25 mg tab | Simple dose | Ambulatory | Mary Doe 

Header

To Qualifier="D" NCPDP01

From Qualifier="P" NPI1111111

MessageID 1004

SentTime 2011-01-20T11:15:00

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00100104

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI1111111

DEANumber DEA111111

StateLicenseNumber LIC11111

ClinicName MINNEAPOLIS CLINIC

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1956-10-14

Name

LastName DOE

FirstName MARY

 © 1st American Systems and Services | www.1asas.com Page 126 of 206 Printed: 8/22/2012 10:24 PM
Gender F

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

MedicationPrescribed

DrugDescription VASERETIC 10/25 TABLET

DrugCoded

ProductCode 00247144004

ProductCodeQualifier ND

Strength 10-25

DrugDBCode 858830

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2011-01-20

Scenario: 10: New Prescription - Diclofenac 75 mg tab | Simple dose | Ambulatory | Mary Doe 

Header

To NCPDP01

From NPI1111111

MessageID 1005

SentTime 2011-01-20T11:17:00

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00100105

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI1111111

 © 1st American Systems and Services | www.1asas.com Page 127 of 206 Printed: 8/22/2012 10:24 PM
DEANumber DEA111111

StateLicenseNumber LIC11111

ClinicName MINNEAPOLIS CLINIC

Name

LastName BROADUS

FirstName CALVIN

MiddleName C

Suffix JR

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1956-10-14

Name

LastName DOE

FirstName MARY

Gender F

Address

AddressLine1 333 EAST RIVER PARKWAY

City MINNEAPOLIS

State MN

ZipCode 55455

CommunicationNumbers

Communication

Number 6126259494

Qualifier TE

MedicationPrescribed

DrugDescription DICLOFENAC SODIUM 75MG ENTERIC COATED TABLET

DrugCoded

ProductCode 00054422225

ProductCodeQualifier ND

Strength 75

DrugDBCode 855926

DrugDBCodeQualifier SCD

FormSourceCode AA

FormCode C42758

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2011-01-20

 © 1st American Systems and Services | www.1asas.com Page 128 of 206 Printed: 8/22/2012 10:24 PM
Scenario: 11: New Prescription - Prednisone 5 mg tab | Tapered dose | Ambulatory | Amy Doe 

Header

To NCPDP02

From NPI6666666

MessageID 2001

SentTime 2011-02-01T14:01:00

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200101

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Prescriber

Identification

NPI NPI6666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1970-08-24

Name

LastName DOE

FirstName AMY

Gender F

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

 © 1st American Systems and Services | www.1asas.com Page 129 of 206 Printed: 8/22/2012 10:24 PM
Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription DELTASONE 5MG TABLET

DrugCoded

ProductCode 55045260607

ProductCodeQualifier ND

Strength 5

DrugDBCode 206954

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 77

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 24

Directions TAKE W/MEALS. DAY 1-14: 2 TABS TWICE A DAY. DAY 15-18: 2 

TABS IN AM AND 1 TAB IN PM. DAY 19-21: 1 TAB TWICE A 

DAY. DAY 22-24: 1 TAB IN AM

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-02-01

Scenario: 11: New Prescription - Diclofenac 75 mg tab | Simple dose | Ambulatory | Amy Doe 

Header

To NCPDP02

From NPI6666666

MessageID 2002

SentTime 2011-02-01T14:03:15

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200102

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Prescriber

Identification

NPI NPI6666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

 © 1st American Systems and Services | www.1asas.com Page 130 of 206 Printed: 8/22/2012 10:24 PM
Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1970-08-24

Name

LastName DOE

FirstName AMY

Gender F

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription DICLOFENAC SODIUM 75MG ENTERIC COATED TABLET

DrugCoded

ProductCode 00054422225

ProductCodeQualifier ND

Strength 75

DrugDBCode 855926

DrugDBCodeQualifier SCD

FormSourceCode AA

FormCode C42758

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 3

WrittenDate

Date 2011-02-01

Scenario: 12: New Prescription - Humulin N 3 ml syringe | Before meals | Ambulatory | Freddy Doe 

Header

To NCPDP02

From NPI5555555

MessageID 2003

SentTime 2011-03-26T15:40:15

 © 1st American Systems and Services | www.1asas.com Page 131 of 206 Printed: 8/22/2012 10:24 PM
Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200103

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Prescriber

Identification

NPI NPI5555555

DEANumber DEA555555

StateLicenseNumber LIC55555

ClinicName GUGGENHEIM CLINIC

Name

LastName BENNETT

FirstName TONY

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 2001-02-01

Name

LastName DOE

FirstName FREDDY

MiddleName DEAN

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription HUMULIN N 100 UNT/ML PREFILLED SYRINGE 3 ML

DrugCoded

ProductCode 00002873099

ProductCodeQualifier ND

 © 1st American Systems and Services | www.1asas.com Page 132 of 206 Printed: 8/22/2012 10:24 PM
Strength 100

DrugDBCode 847199

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42995

StrengthSourceCode AB

StrengthCode C44278

Quantity

Value 1

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48540

Directions TAKE 2 UNITS BEFORE BREAKFAST AND 6 UNITS BEFORE 

DINNER

Refills

Qualifier R

Value 12

Substitutions 0

WrittenDate

Date 2011-03-26

Scenario: 12: New Prescription - Humulin R solution | Sliding scale | Ambulatory | Freddy Doe 

Header

To NCPDP02

From NPI5555555

MessageID 2004

SentTime 2011-03-26T15:42:05

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200104

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Prescriber

Identification

NPI NPI5555555

DEANumber DEA555555

StateLicenseNumber LIC55555

ClinicName GUGGENHEIM CLINIC

Name

LastName BENNETT

FirstName TONY

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

 © 1st American Systems and Services | www.1asas.com Page 133 of 206 Printed: 8/22/2012 10:24 PM
Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 2001-02-01

Name

LastName DOE

FirstName FREDDY

MiddleName DEAN

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription HUMULIN R 100 UNT/ML INJECTIBLE SOLUTION

DrugCoded

ProductCode 00002821599

ProductCodeQualifier ND

Strength 100

DrugDBCode 311036

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42945

StrengthSourceCode AB

StrengthCode C44278

Quantity

Value 10

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C28254

Directions 3X/DAY B4 MEAL.GLUCOSE<12 MMOL/L: 0U. 12.1-14 

MMOL/L: 2U. 14.1-16 MMOL/L: 4U. 16.1-18 MMOL/L: 6U. 

18.1-20 MMOL/L: 8U. >20 MMOL/L: 8U+CALL DR

Refills

Qualifier R

Value 3

Substitutions 0

WrittenDate

Date 2011-03-26

Scenario: 13: Medication History - Request | Denied - Member Not Found | Ambulatory | Sammy Doe 

Header

To PAYER200

From NPI5555555

MessageID 2005

SentTime 2011-03-28T11:01:00

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

 © 1st American Systems and Services | www.1asas.com Page 134 of 206 Printed: 8/22/2012 10:24 PM
Body

RxHistoryRequest

Prescriber

Identification

NPI NPI5555555

DEANumber DEA555555

StateLicenseNumber LIC55555

ClinicName GUGGENHEIM CLINIC

Name

LastName BENNETT

FirstName TONY

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

PatientRelationship 3

Name

LastName DOE

FirstName SAMMY

Gender M

DateOfBirth

Date 2008-12-25

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName NATIONAL PBM

CardholderID 200-19700824-03

ResponsibileParty

LastName DOE

FirstName SAMMY

EffectiveDate

Date 2010-03-28

ExpirationDate

Date 2011-03-28

Consent X

Scenario: 13: Medication History - Response | No medications found | Ambulatory | Sammy Doe 

Header

To NPI5555555

From PAYER200

MessageID 300301

 © 1st American Systems and Services | www.1asas.com Page 135 of 206 Printed: 8/22/2012 10:24 PM
RelatesToMessageID 2005

SentTime 2011-03-28T11:01:03

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Denied

DenialReason MEMBER NOT FOUND

Prescriber

Identification

NPI NPI5555555

DEANumber DEA555555

StateLicenseNumber LIC55555

ClinicName GUGGENHEIM CLINIC

Name

LastName BENNETT

FirstName TONY

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

PatientRelationship 3

Name

LastName DOE

FirstName SAMMY

Gender M

DateOfBirth

Date 2008-12-25

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName NATIONAL PBM

CardholderID 100-19681102

ResponsibileParty

LastName DOE

FirstName SAMMY

EffectiveDate

Date 2010-03-28

 © 1st American Systems and Services | www.1asas.com Page 136 of 206 Printed: 8/22/2012 10:24 PM
ExpirationDate

Date 2011-03-28

Scenario: 13: New Prescription - Amoxicillin 50 mg/ml powd | Weight-based dose | Ambulatory | Sammy Doe 

Header

To NCPDP02

From NPI5555555

MessageID 2006

SentTime 2011-03-28T11:04:29

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200105

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Prescriber

Identification

NPI NPI5555555

DEANumber DEA555555

StateLicenseNumber LIC55555

ClinicName GUGGENHEIM CLINIC

Name

LastName BENNETT

FirstName TONY

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 2008-12-25

Name

LastName DOE

FirstName SAMMY

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

 © 1st American Systems and Services | www.1asas.com Page 137 of 206 Printed: 8/22/2012 10:24 PM
CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 50 MG/ML ORAL SUSPENSION

DrugCoded

ProductCode 55045184803

ProductCodeQualifier ND

Strength 250

DrugDBCode 205729

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42975

StrengthSourceCode AB

StrengthCode C91131

Quantity

Value 150

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C28254

Directions TAKE 340MG THREE TIMES DAILY FOR 7 DAYS

Refills

Qualifier R

Value 0

Substitutions 0

WrittenDate

Date 2011-03-28

Scenario: 13: Fill Status - Response w/prescribed | Generic substitution | Ambulatory | Sammy Doe 

Header

To NPI5555555

From NCPDP02

MessageID A0000001

RelatesToMessageID 2006

SentTime 2011-03-28T13:15:24

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00200105

PrescriberOrderNumber ORD00200105

Body

RxFill

FillStatus

Filled

Note SUBSTITUTED GENERIC

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

 © 1st American Systems and Services | www.1asas.com Page 138 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI5555555

DEANumber DEA555555

StateLicenseNumber LIC55555

ClinicName GUGGENHEIM CLINIC

Name

LastName BENNETT

FirstName TONY

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 2008-12-25

Name

LastName DOE

FirstName SAMMY

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 50 MG/ML ORAL SUSPENSION

DrugCoded

ProductCode 55045184803

ProductCodeQualifier ND

Strength 250

DrugDBCode 205729

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42975

StrengthSourceCode AB

StrengthCode C91131

Quantity

Value 150

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C28254

Directions TAKE 340MG THREE TIMES DAILY FOR 7 DAYS

Refills

 © 1st American Systems and Services | www.1asas.com Page 139 of 206 Printed: 8/22/2012 10:24 PM
Qualifier R

Value 0

Substitutions 0

WrittenDate

Date 2011-03-28

Scenario: 14: New Prescription - Synthroid | Dispense as written | Ambulatory | Cindy Doe 

Header

To NCPDP01

From NPI2222222

MessageID 1006

SentTime 2011-01-21T11:11:11

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00100106

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI2222222

DEANumber DEA222222

StateLicenseNumber LIC22222

ClinicName MINNEAPOLIS CLINIC

Name

LastName PERSSON

FirstName NINA

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1976-08-24

Name

LastName DOE

FirstName CINDY

Gender F

Address

AddressLine1 5500 STEVENS AVE SO

 © 1st American Systems and Services | www.1asas.com Page 140 of 206 Printed: 8/22/2012 10:24 PM
City MINNEAPOLIS

State MN

ZipCode 55419

CommunicationNumbers

Communication

Number 6128219045

Qualifier TE

MedicationPrescribed

DrugDescription SYNTHROID 100 MCG TABLET

DrugCoded

ProductCode 00247129902

ProductCodeQualifier ND

Strength 100

DrugDBCode 966250

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C48152

Quantity

Value 90

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 3

Substitutions 1

WrittenDate

Date 2011-01-21

Scenario: 14: Refill Request - Synthroid | Approved with changes | Ambulatory | Cindy Doe 

Header

To NPI2222222

From NCPDP01

MessageID 108002

SentTime 2011-04-21T14:30:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00100106

PrescriberOrderNumber ORD00100106

Body

RefillRequest

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

 © 1st American Systems and Services | www.1asas.com Page 141 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI2222222

DEANumber DEA222222

StateLicenseNumber LIC22222

ClinicName MINNEAPOLIS CLINIC

Name

LastName PERSSON

FirstName NINA

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1976-08-24

Name

LastName DOE

FirstName CINDY

Gender F

Address

AddressLine1 5500 STEVENS AVE SO

City MINNEAPOLIS

State MN

ZipCode 55419

CommunicationNumbers

Communication

Number 6128219045

Qualifier TE

MedicationPrescribed

DrugDescription SYNTHROID 100 MCG TABLET

DrugCoded

ProductCode 00247129902

ProductCodeQualifier ND

Strength 100

DrugDBCode 966250

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C48152

Quantity

Value 90

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

 © 1st American Systems and Services | www.1asas.com Page 142 of 206 Printed: 8/22/2012 10:24 PM
Refills

Qualifier P

Value 3

Substitutions 1

WrittenDate

Date 2011-01-21

MedicationDispensed

DrugDescription SYNTHROID 100 MCG TABLET

DrugCoded

ProductCode 00247129902

ProductCodeQualifier ND

Strength 100

DrugDBCode 966250

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C48152

Quantity

Value 90

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

Refills

Qualifier P

Value 3

Substitutions 1

LastFillDate

Date 2011-01-21

Scenario: 14: Refill Response - Synthroid | Approved w/Chg resp | Ambulatory | John Doe 

Header

To NCPDP01

From NPI2222222

MessageID 1007

RelatesToMessageID 108002

SentTime 2011-04-27T15:20:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00100106

PrescriberOrderNumber ORD00100107

Body

RefillResponse

Response

ApprovedWithChanges

Note Authorizing single refill. Patient must make appointment

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

 © 1st American Systems and Services | www.1asas.com Page 143 of 206 Printed: 8/22/2012 10:24 PM
CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI2222222

DEANumber DEA222222

StateLicenseNumber LIC22222

ClinicName MINNEAPOLIS CLINIC

Name

LastName PERSSON

FirstName NINA

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1976-08-24

Name

LastName DOE

FirstName CINDY

Gender F

Address

AddressLine1 5500 STEVENS AVE SO

City MINNEAPOLIS

State MN

ZipCode 55419

CommunicationNumbers

Communication

Number 6128219045

Qualifier TE

MedicationPrescribed

DrugDescription SYNTHROID 100 MCG TABLET

DrugCoded

ProductCode 00247129902

ProductCodeQualifier ND

Strength 100

DrugDBCode 966250

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C48152

Quantity

Value 90

CodeListQualifier 38

UnitSourceCode AC

 © 1st American Systems and Services | www.1asas.com Page 144 of 206 Printed: 8/22/2012 10:24 PM
PotencyUnitCode C48542

DaysSupply 90

Directions TAKE ONE TABLET DAILY

Refills

Qualifier A

Value 1

Substitutions 1

WrittenDate

Date 2011-04-27

Scenario: 15: New Prescription - Amoxicillin Suspension | Contains an error | Ambulatory | Susie Doe 

Header

To NCPDP03

From NPI8888888

MessageID 4004

SentTime 2011-02-21T13:30:25

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400104

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI8888888

DEANumber DEA888888

StateLicenseNumber LIC88888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 145 of 206 Printed: 8/22/2012 10:24 PM
Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 2009-01-12

Name

LastName DOE

FirstName SUSIE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 50 MG/ML ORAL SUSPENSION

DrugCoded

ProductCode 55045184803

ProductCodeQualifier ND

Strength SBD

DrugDBCode 205729

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42994

StrengthSourceCode AB

StrengthCode C91131

Quantity

Value 150

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C28254

DaysSupply 7

Directions TAKE 7 ML THREE TIMES DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-02-21

Scenario: 15: Error - Error | System error at receiver | Ambulatory | Susie Doe 

Header

To NPI8888888

From NCPDP03

MessageID 77007

RelatesToMessageID 4004

SentTime 2011-02-21T13:30:35

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400104

Body

Error

Code 602

DescriptionCode 007

 © 1st American Systems and Services | www.1asas.com Page 146 of 206 Printed: 8/22/2012 10:24 PM
Description INTERNAL SYSTEM ERROR. PLEASE RESUBMIT

Scenario: 16: New Prescription - Amoxicillin Suspension | Includes Verify request | Ambulatory | Susie Doe 

Header

To NCPDP03

From NPI8888888

MessageID 4005

SentTime 2011-02-21T13:31:25

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400104

Body

NewRx

Request

ReturnReceipt 1

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI8888888

DEANumber DEA888888

StateLicenseNumber LIC88888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 2009-01-12

 © 1st American Systems and Services | www.1asas.com Page 147 of 206 Printed: 8/22/2012 10:24 PM
Name

LastName DOE

FirstName SUSIE

Gender F

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 50 MG/ML ORAL SUSPENSION

DrugCoded

ProductCode 55045184803

ProductCodeQualifier ND

Strength SBD

DrugDBCode 205729

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42994

StrengthSourceCode AB

StrengthCode C91131

Quantity

Value 150

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C28254

DaysSupply 7

Directions TAKE 7 ML THREE TIMES DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-02-21

Scenario: 16: Status - Status | Status preceding Verify | Ambulatory | Susie Doe 

Header

To NPI8888888

From NCPDP03

MessageID 77008

RelatesToMessageID 4005

SentTime 2011-02-21T13:31:28

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400104

Body

Status

Code 000

Scenario: 16: Verify - Verify | With opt prescribed drug | Ambulatory | Susie Doe 

Header

To NPI8888888

From NCPDP03

 © 1st American Systems and Services | www.1asas.com Page 148 of 206 Printed: 8/22/2012 10:24 PM
MessageID 77009

RelatesToMessageID 4005

SentTime 2011-02-21T13:32:08

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400104

Body

Verify

VerifyStatus

Code 000

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI8888888

DEANumber DEA888888

StateLicenseNumber LIC88888

ClinicName CORCORAN CLINIC

Name

LastName HEWSON

FirstName PAUL

MiddleName DAVID

Prefix DR

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

Name

LastName DOE

FirstName SUSIE

Gender F

DateOfBirth

Date 2009-01-12

Address

AddressLine1 2401 FOXHALL RD NW

 © 1st American Systems and Services | www.1asas.com Page 149 of 206 Printed: 8/22/2012 10:24 PM
City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 50 MG/ML ORAL SUSPENSION

DrugCoded

ProductCode 55045184803

ProductCodeQualifier ND

Strength SBD

DrugDBCode 205729

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42994

StrengthSourceCode AB

StrengthCode C91131

Quantity

Value 150

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C28254

DaysSupply 7

Directions TAKE 7 ML THREE TIMES DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-02-21

Scenario: 17: Medication History - Request | 4 dispenses over 6 mo | Ambulatory | Connie Doe 

Header

To PAYER300

From NPI1010101

MessageID 4005

SentTime 2011-03-24T16:01:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryRequest

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

MiddleName DAVID

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

 © 1st American Systems and Services | www.1asas.com Page 150 of 206 Printed: 8/22/2012 10:24 PM
Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName CONNIE

Gender F

DateOfBirth

Date 1956-07-30

Address

AddressLine1 901 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName NATIONAL PBM

CardholderID 200-19560730-01

ResponsibileParty

LastName DOE

FirstName CONNIE

EffectiveDate

Date 2010-09-24

ExpirationDate

Date 2011-03-24

Consent Y

Scenario: 17: Medication History - Response | Highly populated | Ambulatory | Connie Doe 

Header

To NPI1010101

From PAYER300

MessageID 300303

RelatesToMessageID 4005

SentTime 2011-03-24T16:01:25

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Approved [Tag included without value]

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

 © 1st American Systems and Services | www.1asas.com Page 151 of 206 Printed: 8/22/2012 10:24 PM
MiddleName DAVID

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName CONNIE

Gender F

DateOfBirth

Date 1956-07-30

Address

AddressLine1 901 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER200

PayerName NATIONAL PBM

CardholderID 200-19560730-01

ResponsibileParty

LastName DOE

FirstName CONNIE

EffectiveDate

Date 2010-09-24

ExpirationDate

Date 2011-03-24

Vasotec 5 mg | Highly populated 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

 © 1st American Systems and Services | www.1asas.com Page 152 of 206 Printed: 8/22/2012 10:24 PM
DaysSupply 30

Directions TAKE 1 TABLET TWICE DAILY

Refills

Qualifier R

Value 2

WrittenDate

Date 2010-09-27

LastFillDate

Date 2010-09-30

Diagnosis

ClinicalInformationQualifier 1

Primary

Qualifier DX

Value 401.9

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

DrugUseEvaluation

ServiceReasonCode AR

ProfessionalServiceCode MB

ServiceResultCode 4A

CoAgent

CoAgentID 858817

CoAgentQualifier 38

ClinicalSignificanceCode 3

 © 1st American Systems and Services | www.1asas.com Page 153 of 206 Printed: 8/22/2012 10:24 PM
AcknowledgementReason TOLERABLE DIARRHEA SIDE EFFECT OF ACE INHIBITOR

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 0

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 1

SigFreeText TAKE ONE TABLET TWICE DAILY

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 1

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Vasotec 5 mg | Highly populated 

MedicationDispensed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 00247057830

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE 1 TABLET TWICE DAILY

Refills

Qualifier R

Value 1

WrittenDate

Date 2010-09-27

LastFillDate

Date 2010-11-15

Diagnosis

ClinicalInformationQualifier 1

Primary

Qualifier DX

Value 401.9

Pharmacy

 © 1st American Systems and Services | www.1asas.com Page 154 of 206 Printed: 8/22/2012 10:24 PM
Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

DrugUseEvaluation

ServiceReasonCode AR

ProfessionalServiceCode MB

ServiceResultCode 4A

CoAgent

CoAgentID 858817

CoAgentQualifier 38

ClinicalSignificanceCode 3

AcknowledgementReason TOLERABLE DIARRHEA SIDE EFFECT OF ACE INHIBITOR

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 0

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 1

SigFreeText TAKE ONE TABLET TWICE DAILY

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

 © 1st American Systems and Services | www.1asas.com Page 155 of 206 Printed: 8/22/2012 10:24 PM
DoseQuantity 1

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Enalapril Maleate 5mg | Highly populated 

MedicationDispensed

DrugDescription ENALAPRIL MALEATE 5 MG TABLET

DrugCoded

ProductCode 23490549401

ProductCodeQualifier ND

Strength 5

DrugDBCode 858813

DrugDBCodeQualifier SCD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE 1 TABLET TWICE DAILY

Refills

Qualifier R

Value 2

WrittenDate

Date 2010-12-29

LastFillDate

Date 2011-01-03

Diagnosis

ClinicalInformationQualifier 1

Primary

Qualifier DX

Value 401.9

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

 © 1st American Systems and Services | www.1asas.com Page 156 of 206 Printed: 8/22/2012 10:24 PM
Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

DrugUseEvaluation

ServiceReasonCode AR

ProfessionalServiceCode MB

ServiceResultCode 4A

CoAgent

CoAgentID 858817

CoAgentQualifier 38

ClinicalSignificanceCode 3

AcknowledgementReason TOLERABLE DIARRHEA SIDE EFFECT OF ACE INHIBITOR

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 0

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 1

SigFreeText TAKE ONE TABLET TWICE DAILY

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 1

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Enalapril Maleate 5mg | Highly populated 

 © 1st American Systems and Services | www.1asas.com Page 157 of 206 Printed: 8/22/2012 10:24 PM
MedicationDispensed

DrugDescription ENALAPRIL MALEATE 5 MG TABLET

DrugCoded

ProductCode 23490549401

ProductCodeQualifier ND

Strength 5

DrugDBCode 858813

DrugDBCodeQualifier SCD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE 1 TABLET TWICE DAILY

Refills

Qualifier R

Value 1

WrittenDate

Date 2010-12-29

LastFillDate

Date 2011-02-01

Diagnosis

ClinicalInformationQualifier 1

Primary

Qualifier DX

Value 401.9

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

 © 1st American Systems and Services | www.1asas.com Page 158 of 206 Printed: 8/22/2012 10:24 PM
State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

DrugUseEvaluation

ServiceReasonCode AR

ProfessionalServiceCode MB

ServiceResultCode 4A

CoAgent

CoAgentID 858817

CoAgentQualifier 38

ClinicalSignificanceCode 3

AcknowledgementReason TOLERABLE DIARRHEA SIDE EFFECT OF ACE INHIBITOR

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 0

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 1

SigFreeText TAKE ONE TABLET TWICE DAILY

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 1

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Scenario: 17: New Prescription - Enalapril Maleate 10 MG | Structured Sig & Obs | Ambulatory | Connie Doe 

Header

To NCPDP03

From NPI1010101

MessageID 4006

SentTime 2011-03-24T16:10:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400105

Body

NewRx

Pharmacy

 © 1st American Systems and Services | www.1asas.com Page 159 of 206 Printed: 8/22/2012 10:24 PM
Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1956-07-30

Name

LastName DOE

FirstName CONNIE

Gender F

Address

AddressLine1 901 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

MedicationPrescribed

DrugDescription ENALAPRIL MALEATE 10 MG TABLET

DrugCoded

ProductCode 21695048830

ProductCodeQualifier ND

Strength 10

DrugDBCode 858817

DrugDBCodeQualifier SCD

 © 1st American Systems and Services | www.1asas.com Page 160 of 206 Printed: 8/22/2012 10:24 PM
FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 1

WrittenDate

Date 2011-03-24

Diagnosis

ClinicalInformationQualifier 1

Primary

Qualifier DX

Value 401.9

Secondary

Qualifier DX

Value 784.0

DrugUseEvaluation

ServiceReasonCode AR

ProfessionalServiceCode MB

ServiceResultCode 4A

CoAgent

CoAgentID 858817

CoAgentQualifier 38

ClinicalSignificanceCode 3

AcknowledgementReason TOLERABLE DIARRHEA SIDE EFFECT OF ACE INHIBITOR

StructuredSIG

RepeatingSIG

SigSequencePositionNumber 1

CodeSystem

SNOMEDVersion 2010_07_31

FMTVersion 2011_04_01

FreeText

SigFreeTextStringIndicator 1

SigFreeText TAKE ONE TABLET DAILY

Dose

DoseCompositeIndicator 1

DoseDeliveryMethodText TAKE

DoseDeliveryMethodCodeQualifier 1

DoseDeliveryMethodCode 419652001

DoseQuantity 1

DoseFormText TABLET

DoseFormCodeQualifier 2

DoseFormCode C42998

RouteofAdministration

RouteofAdministrationText BY MOUTH

RouteofAdministrationCodeQualifier 1

RouteofAdministrationCode 26643006

Timing

FrequencyNumericValue 1

FrequencyUnitsText Day

FrequencyUnitsCodeQualifier 1

FrequencyUnitsCode 258703001

Observation

Measurement

 © 1st American Systems and Services | www.1asas.com Page 161 of 206 Printed: 8/22/2012 10:24 PM
Dimension WG

Value 158

ObservationDate

DateTime 2011-03-24T16:00:00

MeasurementDataQualifier 1

MeasurementSourceCode AC

MeasurementUnitCode C48531

Scenario: 17: Fill Status - Response w/prescribed | Dispense as written | Ambulatory | Connie Doe 

Header

To NPI1010101

From NCPDP03

MessageID 77010

RelatesToMessageID 4006

SentTime 2011-03-24T17:30:01

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00400105

PrescriberOrderNumber ORD00400105

Body

RxFill

FillStatus

NotFilled

Note NOT PICKED UP BY PATIENT. RETURNED TO STOCK

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

 © 1st American Systems and Services | www.1asas.com Page 162 of 206 Printed: 8/22/2012 10:24 PM
Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1956-07-30

Name

LastName DOE

FirstName CONNIE

Gender F

Address

AddressLine1 901 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

MedicationPrescribed

DrugDescription ENALAPRIL MALEATE 10 MG TABLET

DrugCoded

ProductCode 21695048830

ProductCodeQualifier ND

Strength 10

DrugDBCode 858817

DrugDBCodeQualifier SCD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET DAILY

Refills

Qualifier R

Value 1

WrittenDate

Date 2011-03-24

Scenario: 18: New Prescrption - Amoxil 500 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Header

To NCPDP02

From NPI6666666

MessageID 2007

SentTime 2011-04-02T17:10:11

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200106

Body

NewRx

Pharmacy

 © 1st American Systems and Services | www.1asas.com Page 163 of 206 Printed: 8/22/2012 10:24 PM
Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI6666666

DEANumber DEA666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

Suffix MD

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1986-01-01

Name

LastName DOE

FirstName KIM

Gender F

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 500 MG CAPSULE

DrugCoded

ProductCode 66267038230

ProductCodeQualifier ND

Strength 500

DrugDBCode 200998

 © 1st American Systems and Services | www.1asas.com Page 164 of 206 Printed: 8/22/2012 10:24 PM
DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 10

Directions TAKE ONE CAPSULE THREE TIMES DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-02

Scenario: 19: Cancel Prescription - Amoxil 500 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Header

To NCPDP02

From NPI6666666

MessageID 2007

SentTime 2011-04-03T11:14:41

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200106

Body

CancelRx

Request

ChangeofPrescriptionStatusFlag C

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI6666666

DEANumber DEA666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

 © 1st American Systems and Services | www.1asas.com Page 165 of 206 Printed: 8/22/2012 10:24 PM
Suffix MD

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1986-01-01

Name

LastName DOE

FirstName KIM

Gender F

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription AMOXIL 500 MG CAPSULE

DrugCoded

ProductCode 66267038230

ProductCodeQualifier ND

Strength 500

DrugDBCode 200998

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 10

Directions TAKE ONE CAPSULE THREE TIMES DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-02

Scenario: 19: Cancel Response - Amoxil 500 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Header

To NPI6666666

From NCPDP02

MessageID A0000002

RelatesToMessageID 2007

SentTime 2011-04-03T17:17:40

 © 1st American Systems and Services | www.1asas.com Page 166 of 206 Printed: 8/22/2012 10:24 PM
Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200106

Body

CancelRxResponse

Response

Approved

Note DISPENSING CANCELLED

Scenario: 20: New Prescrption - Zithromax 250 MG Cap | Oral capsule | Ambulatory | Kim Doe 

Header

To NCPDP02

From NPI6666666

MessageID 2008

SentTime 2011-04-03T17:18:45

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200107

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI6666666

DEANumber DEA666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

Suffix MD

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

 © 1st American Systems and Services | www.1asas.com Page 167 of 206 Printed: 8/22/2012 10:24 PM
Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1986-01-01

Name

LastName DOE

FirstName KIM

Gender F

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription ZITHROMAX 250 MG CAPSULE

DrugCoded

ProductCode 60491072206

ProductCodeQualifier ND

Strength 250

DrugDBCode 105259

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 9

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48480

DaysSupply 8

Directions TAKE 2 CAPSULES ON DAY 1. THEN TAKE 1 CAPSULE DAILY ON 

DAYS 2-8

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-03

Scenario: 21: New Prescription - Vicodin 10/660 | Controlled substance III | Ambulatory | Albert Doe 

Header

To NCPDP03

From NPI1010101

MessageID 4008

SentTime 2011-04-04T08:47:45

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400106

Body

NewRx

 © 1st American Systems and Services | www.1asas.com Page 168 of 206 Printed: 8/22/2012 10:24 PM
Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

DEANumber DEA330033

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1981-07-06

Name

LastName DOE

FirstName ALBERT

Gender M

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription VICODIN 10/660 10 MG TABLET

DrugCoded

ProductCode 54868494000

ProductCodeQualifier ND

Strength 10

 © 1st American Systems and Services | www.1asas.com Page 169 of 206 Printed: 8/22/2012 10:24 PM
DrugDBCode 856912

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

DEASchedule C48676

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

Directions TAKE ONE TABLET EVERY 4-6 HOURS AS NEEDED FOR PAIN

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-04

EffectiveDate

Date 2011-04-04

DrugCoverageStatusCode SI

Scenario: 22: Cancel Prescription - Vicodin 10/660 | Controlled substance III | Ambulatory | Albert Doe 

Header

To NCPDP03

From NPI1010101

MessageID 4008

SentTime 2011-04-04T08:47:45

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400106

Body

CancelRx

Request

ChangeofPrescriptionStatusFlag C

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

DEANumber DEA330033

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

 © 1st American Systems and Services | www.1asas.com Page 170 of 206 Printed: 8/22/2012 10:24 PM
ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1981-07-06

Name

LastName DOE

FirstName ALBERT

Gender M

Address

AddressLine1 2401 FOXHALL RD NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023373051

Qualifier TE

MedicationPrescribed

DrugDescription VICODIN 10/660 10 MG TABLET

DrugCoded

ProductCode 54868494000

ProductCodeQualifier ND

Strength 10

DrugDBCode 856912

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

DEASchedule C48676

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

Directions TAKE ONE TABLET EVERY 4-6 HOURS AS NEEDED FOR PAIN

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-04

EffectiveDate

Date 2011-04-04

Scenario: 22: Cancel Response - Vicodin 10/660 | Controlled substance III | Ambulatory | Albert Doe 

 © 1st American Systems and Services | www.1asas.com Page 171 of 206 Printed: 8/22/2012 10:24 PM
Header

To NPI1010101

From NCPDP03

MessageID 77011

RelatesToMessageID 4008

SentTime 2011-04-04T08:59:25

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00400106

Body

CancelRxResponse

Request

ChangeofPrescriptionStatusFlag C

Response

Approved

Note DISPENSING CANCELLED

Scenario: 23: New Prescription - Biaxin 250 MG Tablet | Simple directions | Ambulatory | Dean Doe 

Header

To NCPDP02

From NPI7777777

MessageID 2008

SentTime 2011-04-09T13:23:25

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200107

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

 © 1st American Systems and Services | www.1asas.com Page 172 of 206 Printed: 8/22/2012 10:24 PM
Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1968-12-13

Name

LastName DOE

FirstName DEAN

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription BIAXIN 250 MG TABLET

DrugCoded

ProductCode 52959044210

ProductCodeQualifier ND

Strength 250

DrugDBCode 205863

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 20

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 10

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-09

Scenario: 24: Change Request - SULFAMETHOXAZOLE 400MG TABLET | Denied | Ambulatory | Dean Doe 

Header

To NPI7777777

From NCPDP02

MessageID A0000003

RelatesToMessageID 2008

 © 1st American Systems and Services | www.1asas.com Page 173 of 206 Printed: 8/22/2012 10:24 PM
SentTime 2011-04-09T14:43:25

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00200107

PrescriberOrderNumber ORD00200107

Body

RxChangeRequest

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1968-12-13

Name

LastName DOE

FirstName DEAN

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

 © 1st American Systems and Services | www.1asas.com Page 174 of 206 Printed: 8/22/2012 10:24 PM
ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription BIAXIN 250 MG TABLET

DrugCoded

ProductCode 52959044210

ProductCodeQualifier ND

Strength 250

DrugDBCode 205863

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 20

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 10

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-09

SULFAMETHOXAZOLE 400MG TABLET | Requested med 

MedicationRequested

DrugDescription SULFAMETHOXAZOLE 400MG/TRIMETHOPRIM 80MG TABLET

DrugCoded

ProductCode 12634008898

ProductCodeQualifier ND

Strength 400-80

DrugDBCode 198334

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 20

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 10

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

Scenario: 24: Change Response - SULFAMETHOXAZOLE 400MG TABLET | Denied | Ambulatory | Dean Doe 

Header

To NCPDP02

From NPI7777777

MessageID 2009

RelatesToMessageID A0000003

 © 1st American Systems and Services | www.1asas.com Page 175 of 206 Printed: 8/22/2012 10:24 PM
SentTime 2011-04-09T16:10:30

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00200107

PrescriberOrderNumber ORD00200108

Body

RxChangeResponse

Response

Denied

DenialReason TO AVOID INTOLERANCE, WILL PRESCRIBE BRAND VERSION - 

TO FOLLOW

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1968-12-13

Name

LastName DOE

FirstName DEAN

Gender M

Address

 © 1st American Systems and Services | www.1asas.com Page 176 of 206 Printed: 8/22/2012 10:24 PM
AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

Scenario: 24: New Prescription - Septra 400/80 Tablet | No Substitutions | Ambulatory | Dean Doe 

Header

To NCPDP02

From NPI7777777

MessageID 2010

SentTime 2011-04-09T16:11:30

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200109

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

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Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1968-12-13

Name

LastName DOE

FirstName DEAN

Gender M

Address

AddressLine1 11 W 53RD ST

AddressLine2 Apt 121

City NEW YORK

State NY

ZipCode 10019

CommunicationNumbers

Communication

Number 2127089400

Qualifier TE

MedicationPrescribed

DrugDescription SEPTRA 400/80 TABLET

DrugCoded

ProductCode 61570005201

ProductCodeQualifier ND

Strength 400-80

DrugDBCode 823998

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 20

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 10

Directions TAKE ONE TABLET TWICE DAILY

Note PRESCRIBING SEPTRA, WHICH IS BETTER TOLERATED BY 

PATIENT

Refills

Qualifier R

Value 0

Substitutions 1

WrittenDate

Date 2011-04-09

Scenario: 25: New Prescription - Biaxin 250 MG Tablet | DUE segment populated | Ambulatory | Terry Doe 

Header

To NCPDP03

From NPI1010101

MessageID 4009

SentTime 2011-04-11T12:21:30

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00300102

Body

 © 1st American Systems and Services | www.1asas.com Page 178 of 206 Printed: 8/22/2012 10:24 PM
NewRx

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

DEANumber DEA330033

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

CommunicationNumbers

Communication

Number 2023872151X238

Qualifier TE

Communication

Number 2023872436

Qualifier FX

Prescriber

Identification

NPI NPI1010101

DEANumber DEA101010

StateLicenseNumber LIC101010

ClinicName CORCORAN CLINIC

Name

LastName HARTLEY

FirstName ANNA-KATHERINE

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Communication

Number 2026391800

Qualifier FX

Patient 

DateOfBirth

Date 1973-01-15

Name

LastName DOE

FirstName TERRY

Gender M

Address

AddressLine1 901 NEW YORK AVE NW

City NEW YORK

State NY

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

MedicationPrescribed

DrugDescription BIAXIN 250 MG TABLET

DrugCoded

ProductCode 52959044210

ProductCodeQualifier ND

 © 1st American Systems and Services | www.1asas.com Page 179 of 206 Printed: 8/22/2012 10:24 PM
Strength 250

DrugDBCode 205863

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28254

Quantity

Value 20

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 10

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-11

DrugUseEvaluation

ServiceReasonCode DA

ProfessionalServiceCode PA

ServiceResultCode 4A

CoAgent

CoAgentID 52959044210

CoAgentQualifier 36

ClinicalSignificanceCode 2

AcknowledgementReason PATIENT HAD STOMACH UPSET IN PREVIOUS TREATMENT. 

NOT ALLERGIC

Scenario: 27: Census - Admission | with ALG and DIA | LTPAC | Frieda Doe 

Header

To NCPDP04

From NPI9999999

MessageID CENSUS001

SentTime 2011-05-01T09:15:10

Body

Census

Request

ChangeRequestType A

CensusEffectiveDate 2011-05-01

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023426230

Qualifier TE

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Facility

Identification

NPI NPI1234567

DEANumber DEA123456

FacilityName MOCA COMMUNITY

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

Patient 

DateOfBirth

Date 1926-03-01

Name

LastName DOE

FirstName FRIEDA

Gender F

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023426230

Qualifier TE

PatientLocation

FacilityUnit EAST WING

Bed A

Room 201

Allergy

NoKnownAllergies N

SourceOfInformation P

EffectiveDate

Date 2001-01-02

AdverseEvent

ItemDescriptionLong DRUG INTOLERANCE

ItemNumber 59037007

CodeListQualifier LD

DrugProductCoded

ItemDescriptionLong PENICILLINS

ItemNumber N0000011281

CodeListQualifier RT

ReactionCoded

ItemDescriptionLong ANGIOEDEMA

ItemNumber 41291007

CodeListQualifier LD

SeverityCoded

ItemDescriptionLong MODERATE

ItemNumber 6736007

CodeListQualifier LD

Allergy

NoKnownAllergies N

SourceOfInformation P

EffectiveDate

Date 1991-01-02

AdverseEvent

ItemDescriptionLong FOOD INTOLERANCE

ItemNumber 235719002

CodeListQualifier LD

DrugProductCoded

ItemDescriptionLong LACTOSE

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ItemNumber J2B2A4N98G

CodeListQualifier UN

ReactionCoded

ItemDescriptionLong NAUSEA

ItemNumber 422587007

CodeListQualifier LD

SeverityCoded

ItemDescriptionLong MODERATE TO SEVERE

ItemNumber 371924009

CodeListQualifier LD

DiagnosisGeneral

SourceOfInformation P

EffectiveDate

Date 2010-04-20

ProblemType

ItemDescriptionLong DIAGNOSIS

ItemNumber 282291009

CodeListQualifier LD

ProblemNameCoded

ItemDescriptionLong PERSISTENT COUGH

ItemNumber 284523002

CodeListQualifier LD

DiagnosisGeneral

SourceOfInformation P

EffectiveDate

Date 2010-04-20

ProblemType

ItemDescriptionLong DIAGNOSIS

ItemNumber 282291009

CodeListQualifier LD

ProblemNameCoded

ItemDescriptionLong TYPE 2 DIABETES

ItemNumber 44054006

CodeListQualifier LD

DiagnosisGeneral

SourceOfInformation P

EffectiveDate

Date 1999-03-20

ProblemType

ItemDescriptionLong DIAGNOSIS

ItemNumber 282291009

CodeListQualifier LD

ProblemNameCoded

ItemDescriptionLong ATRIAL FIBRILLATION

ItemNumber 49436004

CodeListQualifier LD

Scenario: 29: Refill Request - Lasix 20 MG | Denied - new Rx to follow | Ambulatory | Cindy Doe 

Header

To NPI3333333

From NCPDP01

MessageID 108002

SentTime 2011-04-21T14:30:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00100099

PrescriberOrderNumber ORD00100099

Body

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RefillRequest

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI3333333

DEANumber DEA333333

StateLicenseNumber LIC33333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1938-10-26

Name

LastName DOE

FirstName COLLEEN

Gender F

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription LASIX 20 MG TABLET

DrugCoded

ProductCode 58056013510

ProductCodeQualifier ND

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Strength 20

DrugDBCode 200801

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET EACH MORNING

Refills

Qualifier P

Value 3

Substitutions 1

WrittenDate

Date 2011-01-20

MedicationDispensed

DrugDescription LASIX 20 MG TABLET

DrugCoded

ProductCode 58056013510

ProductCodeQualifier ND

Strength 20

DrugDBCode 200801

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 87

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET EACH MORNING

Refills

Qualifier P

Value 3

Substitutions 1

LastFillDate

Date 2011-03-20

Scenario: 29: Refill Response - Lasix 20 MG | Denied - new Rx to follow | Ambulatory | John Doe 

Header

To NCPDP01

From NPI3333333

MessageID 1009

RelatesToMessageID 108002

SentTime 2011-04-21T15:31:20

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00100099

PrescriberOrderNumber ORD00100099

Body

 © 1st American Systems and Services | www.1asas.com Page 184 of 206 Printed: 8/22/2012 10:24 PM
RefillResponse

Response

DeniedNewPrescriptionToFollow

DenialReason SWITCHING TO GENERIC

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI3333333

DEANumber DEA333333

StateLicenseNumber LIC33333

ClinicName MINNEAPOLIS CLINIC

Name

LastName BAKER

FirstName CHET

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1938-10-26

Name

LastName DOE

FirstName COLLEEN

Gender F

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription LASIX 20 MG TABLET

 © 1st American Systems and Services | www.1asas.com Page 185 of 206 Printed: 8/22/2012 10:24 PM
DrugCoded

ProductCode 58056013510

ProductCodeQualifier ND

Strength 20

DrugDBCode 200801

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET EACH MORNING

Refills

Qualifier A

Value 3

Substitutions 1

WrittenDate

Date 2011-01-20

Scenario: 29: New Prescription - Furosemide 20mg Tab | Generic | Ambulatory | Colleen Doe 

Header

To NCPDP01

From NPI3333333

MessageID 1010

SentTime 2011-04-21T15:33:40

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00100108

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

Address

AddressLine1 1750 HENNEPIN AVE

City MINNEAPOLIS

State MN

ZipCode 55403

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Communication

Number 6123757633

Qualifier FX

Prescriber

Identification

NPI NPI3333333

DEANumber DEA333333

StateLicenseNumber LIC33333

ClinicName MINNEAPOLIS CLINIC

 © 1st American Systems and Services | www.1asas.com Page 186 of 206 Printed: 8/22/2012 10:24 PM
Name

LastName BAKER

FirstName CHET

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1938-10-26

Name

LastName DOE

FirstName COLLEEN

Gender F

Address

AddressLine1 518 SECOND ST SE

City MINNEAPOLIS

State MN

ZipCode 55414

CommunicationNumbers

Communication

Number 6126239176

Qualifier TE

MedicationPrescribed

DrugDescription FUROSEMIDE 20 MG TABLET

DrugCoded

ProductCode 00440755510

ProductCodeQualifier ND

Strength 20

DrugDBCode 310429

DrugDBCodeQualifier SCD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET EACH MORNING

Refills

Qualifier R

Value 2

Substitutions 0

WrittenDate

Date 2011-01-20

Scenario: 33: Change Request - Voltaren 50 MG Tab | Request for prior auth | Ambulatory | Tabatha Doe 

Header

 © 1st American Systems and Services | www.1asas.com Page 187 of 206 Printed: 8/22/2012 10:24 PM
To NPI6666666

From NCPDP02

MessageID A0000004

RelatesToMessageID 2011

SentTime 2011-04-24T11:10:40

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200110

Body

RxChangeRequest

Request

ChangeRequestType P

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI6666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1963-09-24

Name

LastName DOE

FirstName TABATHA

Gender F

Address

 © 1st American Systems and Services | www.1asas.com Page 188 of 206 Printed: 8/22/2012 10:24 PM
AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription VOLTAREN 50 MG TABLET

DrugCoded

ProductCode 54868089601

ProductCodeQualifier ND

Strength 50

DrugDBCode 855907

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42758

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 15

Directions TAKE ONE TABLET TWICE DAILY

Note PATIENT'S INSURANCE REQUIRES A PRIOR AUTHORIZATION

Refills

Qualifier R

Value 0

Substitutions 1

WrittenDate

Date 2011-04-24

Scenario: 33: Change Response - Voltaren 50 MG Tab | Request for prior auth | Ambulatory | Tabatha Doe 

Header

To NCPDP02

From NPI6666666

MessageID 2012

RelatesToMessageID A0000004

SentTime 2011-04-24T13:05:40

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200110

Body

RxChangeResponse

Response

Approved [Tag included without value]

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

 © 1st American Systems and Services | www.1asas.com Page 189 of 206 Printed: 8/22/2012 10:24 PM
State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI6666666

StateLicenseNumber LIC66666

ClinicName GUGGENHEIM CLINIC

Name

LastName DUFFY

FirstName AIMEE

MiddleName ANNE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 101280173

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1963-09-24

Name

LastName DOE

FirstName TABATHA

Gender F

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription VOLTAREN 50 MG TABLET

DrugCoded

ProductCode 54868089601

ProductCodeQualifier ND

Strength 50

DrugDBCode 855907

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42758

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

 © 1st American Systems and Services | www.1asas.com Page 190 of 206 Printed: 8/22/2012 10:24 PM
UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 15

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

Substitutions 1

WrittenDate

Date 2011-04-24

Scenario: 34: New Prescrption - Hydrocot 50 MG Tab | Oral tablet | Ambulatory | Timothy Doe 

Header

To NCPDP02

From NPI7777777

MessageID 2013

SentTime 2011-04-25T14:15:40

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00200111

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

 © 1st American Systems and Services | www.1asas.com Page 191 of 206 Printed: 8/22/2012 10:24 PM
Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1966-03-05

Name

LastName DOE

FirstName TIMOTHY

Gender M

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription HYDROCOT 50 MG TABLET

DrugCoded

ProductCode 463626810

ProductCodeQualifier ND

Strength 50

DrugDBCode 542850

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET EACH MORNING

Refills

Qualifier R

Value 0

Substitutions 0

WrittenDate

Date 2011-04-25

Scenario: 35: Change Request - Vasotec 5 MG Tablet | Therapeutic IC - approved | Ambulatory | Timothy Doe 

Header

To NPI7777777

From NCPDP02

MessageID A0000005

RelatesToMessageID 2013

SentTime 2011-04-26T11:31:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00200111

PrescriberOrderNumber ORD00200111

Body

 © 1st American Systems and Services | www.1asas.com Page 192 of 206 Printed: 8/22/2012 10:24 PM
RxChangeRequest

Request

ChangeRequestType T

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1966-03-05

Name

LastName DOE

FirstName TIMOTHY

Gender M

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

MedicationPrescribed

DrugDescription HYDROCOT 50 MG TABLET

DrugCoded

 © 1st American Systems and Services | www.1asas.com Page 193 of 206 Printed: 8/22/2012 10:24 PM
ProductCode 463626810

ProductCodeQualifier ND

Strength 50

DrugDBCode 542850

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET EACH MORNING

Refills

Qualifier R

Value 0

Substitutions 0

WrittenDate

Date 2011-04-25

Vasotec 5 MG Tablet | Therapeutic IC - approved 

MedicationRequested

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 53002102102

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Note PATIENT HAS AN ALLERGY TO THE PRESCRIBED MEDICATION

Refills

Qualifier R

Value 0

Scenario: 35: Change Response - Vasotec 5 MG Tablet | Therapeutic IC - approved | Ambulatory | Timothy Doe 

Header

To NPI7777777

From NCPDP02

MessageID 2014

RelatesToMessageID A0000005

SentTime 2011-04-26T12:01:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

 © 1st American Systems and Services | www.1asas.com Page 194 of 206 Printed: 8/22/2012 10:24 PM
RxReferenceNumber PHARM00200111

PrescriberOrderNumber ORD00200112

Body

RxChangeResponse

Response

Approved [Tag included without value]

Pharmacy

Identification

NCPDPID NCPDP02

NPI NPI1234567

StoreName WHITNEY PHARMACY

Address

AddressLine1 945 MADISON AVE

City NEW YORK

State NY

ZipCode 10021

CommunicationNumbers

Communication

Number 2125703600

Qualifier TE

Communication

Number 2126060388

Qualifier FX

Prescriber

Identification

NPI NPI7777777

DEANumber DEA777777

StateLicenseNumber LIC77777

ClinicName GUGGENHEIM CLINIC

Name

LastName ADKINS

FirstName ADELE

MiddleName LAURIE

Prefix DR

Address

AddressLine1 1071 FIFTH AVE

City NEW YORK

State NY

ZipCode 10128

CommunicationNumbers

Communication

Number 2124233500

Qualifier TE

Communication

Number 2124233640

Qualifier FX

Patient 

DateOfBirth

Date 1966-03-05

Name

LastName DOE

FirstName TIMOTHY

Gender M

Address

AddressLine1 235 BOWERY

City NEW YORK

State NY

ZipCode 10002

CommunicationNumbers

Communication

Number 2122191222

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 195 of 206 Printed: 8/22/2012 10:24 PM
MedicationPrescribed

DrugDescription VASOTEC 5 MG TABLET

DrugCoded

ProductCode 53002102102

ProductCodeQualifier ND

Strength 5

DrugDBCode 858815

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 60

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 30

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-25

Scenario: 36: New Prescription - Celebrex 50 MG Capsule | Dispense as written | Pain medication | Amanda Doe 

Header

To NCPDP01

From NPI2222222

MessageID 2015

SentTime 2011-04-27T13:13:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

PrescriberOrderNumber ORD00100113

Body

NewRx

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI2222222

DEANumber DEA222222

StateLicenseNumber LIC22222

ClinicName MINNEAPOLIS CLINIC

Name

LastName PERSSON

FirstName NINA

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

 © 1st American Systems and Services | www.1asas.com Page 196 of 206 Printed: 8/22/2012 10:24 PM
City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1981-09-30

Name

LastName DOE

FirstName AMANDA

Gender F

Address

AddressLine1 5500 STEVENS AVE SO

City MINNEAPOLIS

State MN

ZipCode 55419

CommunicationNumbers

Communication

Number 6128219045

Qualifier TE

MedicationPrescribed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48480

Directions TAKE ONE TABLET EVERY FOUR HOURS AS NEEDED FOR PAIN

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-27

Scenario: 37: Change Request - Cataflam 50 MG Tablet | Formulary interchange | Ambulatory | Amanda Doe 

Header

To NPI7777777

From NCPDP02

MessageID A0000006

RelatesToMessageID 2016

SentTime 2011-04-28T09:15:10

Security

Sender

SecondaryIdentification PASSWORD

 © 1st American Systems and Services | www.1asas.com Page 197 of 206 Printed: 8/22/2012 10:24 PM
TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00200113

PrescriberOrderNumber ORD00200113

Body

RxChangeRequest

Request [Tag included without value]

Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI2222222

DEANumber DEA222222

StateLicenseNumber LIC22222

ClinicName MINNEAPOLIS CLINIC

Name

LastName PERSSON

FirstName NINA

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1981-09-30

Name

LastName DOE

FirstName AMANDA

Gender F

Address

AddressLine1 5500 STEVENS AVE SO

City MINNEAPOLIS

State MN

ZipCode 55419

CommunicationNumbers

Communication

Number 6128219045

Qualifier TE

MedicationPrescribed

DrugDescription CELEBREX 50 MG CAPSULE

DrugCoded

ProductCode 65427004901

ProductCodeQualifier ND

Strength 50

DrugDBCode 686381

 © 1st American Systems and Services | www.1asas.com Page 198 of 206 Printed: 8/22/2012 10:24 PM
DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C25158

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48480

Directions TAKE ONE TABLET EVERY FOUR HOURS AS NEEDED FOR PAIN

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-27

Cataflam 50 MG Tablet | Formulary interchange 

MedicationRequested

DrugDescription CATAFLAM 50 MG TABLET

DrugCoded

ProductCode 17088015101

ProductCodeQualifier ND

Strength 50

DrugDBCode 855944

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 15

Directions TAKE ONE TABLET TWICE DAILY

Note PATIENT'S FORMULARY DOES NOT COVER CELEBREX

Refills

Qualifier R

Value 0

Scenario: 37: Change Response - Cataflam 50 MG Tablet | Formulary interchange | Ambulatory | Amanda Doe 

Header

To NPI7777777

From NCPDP02

MessageID 2014

RelatesToMessageID A0000005

SentTime 2011-04-28T11:12:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

RxReferenceNumber PHARM00200113

PrescriberOrderNumber ORD00200114

Body

RxChangeResponse

Response

Approved [Tag included without value]

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Pharmacy

Identification

NCPDPID NCPDP01

NPI NPI1011001

StoreName WALKER PHARMACY

CommunicationNumbers

Communication

Number 6123757600

Qualifier TE

Prescriber

Identification

NPI NPI2222222

DEANumber DEA222222

StateLicenseNumber LIC22222

ClinicName MINNEAPOLIS CLINIC

Name

LastName PERSSON

FirstName NINA

Prefix DR

Address

AddressLine1 2400 THIRD AVENUE SO

AddressLine2 STE 400

City MINNEAPOLIS

State MN

ZipCode 55404

CommunicationNumbers

Communication

Number 6128703000

Qualifier TE

Communication

Number 6128703100

Qualifier FX

Patient 

DateOfBirth

Date 1981-09-30

Name

LastName DOE

FirstName AMANDA

Gender F

Address

AddressLine1 5500 STEVENS AVE SO

City MINNEAPOLIS

State MN

ZipCode 55419

CommunicationNumbers

Communication

Number 6128219045

Qualifier TE

MedicationPrescribed

DrugDescription CATAFLAM 50 MG TABLET

DrugCoded

ProductCode 17088015101

ProductCodeQualifier ND

Strength 50

DrugDBCode 855944

DrugDBCodeQualifier SBD

FormSourceCode AA

FormCode C42998

StrengthSourceCode AB

StrengthCode C28253

Quantity

Value 30

 © 1st American Systems and Services | www.1asas.com Page 200 of 206 Printed: 8/22/2012 10:24 PM
CodeListQualifier 38

UnitSourceCode AC

PotencyUnitCode C48542

DaysSupply 15

Directions TAKE ONE TABLET TWICE DAILY

Refills

Qualifier R

Value 0

WrittenDate

Date 2011-04-28

Scenario: 38: Medication History - Request | Lightly populated | Ambulatory | Martin Doe 

Header

To PAYER100

From NPI9999999

MessageID 5005

SentTime 2011-04-30T09:15:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryRequest

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN HOSPITAL EMERGENCY DEPT

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 901 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName MARTIN

Gender M

DateOfBirth

Date 1923-11-12

Address

AddressLine1 1800 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472789

Qualifier TE

 © 1st American Systems and Services | www.1asas.com Page 201 of 206 Printed: 8/22/2012 10:24 PM
BenefitsCoordination

PayerIdentification

PayerID PAYER100

PayerName USA BENEFITS

CardholderID 100-19231112-01

ResponsibileParty

LastName DOE

FirstName MARTIN

EffectiveDate

Date 2011-03-30

ExpirationDate

Date 2011-04-30

Consent Y

Scenario: 38: Medication History - Response | Lightliy Populated | Ambulatory | Martin Doe 

Header

To NPI9999999

From PAYER100

MessageID 300393

RelatesToMessageID 5005

SentTime 2011-04-30T09:15:10

Security

Sender

SecondaryIdentification PASSWORD

TertiaryIdentification 3RYIDENTIFIER

Receiver [Tag included without value]

Body

RxHistoryResponse

Response

Approved [Tag included without value]

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName CORCORAN HOSPITAL EMERGENCY DEPT

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 901 NEW YORK AVE NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023472787

Qualifier TE

Patient 

PatientRelationship 1

Name

LastName DOE

FirstName MARTIN

Gender M

DateOfBirth

Date 1923-11-12

Address

AddressLine1 1800 NEW YORK AVE NW

City WASHINGTON

 © 1st American Systems and Services | www.1asas.com Page 202 of 206 Printed: 8/22/2012 10:24 PM
State DC

ZipCode 20001

CommunicationNumbers

Communication

Number 2023472789

Qualifier TE

BenefitsCoordination

PayerIdentification

PayerID PAYER100

PayerName USA BENEFITS

CardholderID 100-19231112-01

ResponsibileParty

LastName DOE

FirstName MARTIN

EffectiveDate

Date 2011-03-30

ExpirationDate

Date 2011-04-30

Response | Lightly populated - Bupropion 

MedicationDispensed

DrugDescription 12 HR BUPROPION HYDROCHLORIDE 100 MG EXTENDED 

RELEASE TABLET

Directions TAKE 1 TABLET DAILY

LastFillDate

Date 2011-04-01

Pharmacy

Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI9999999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Response | Lightly populated - Inderal 

MedicationDispensed

DrugDescription ENALAPRIL MALEATE 5 MG TABLET

Directions TAKE 1 TABLET TWICE DAILY

LastFillDate

Date 2011-04-01

Pharmacy

 © 1st American Systems and Services | www.1asas.com Page 203 of 206 Printed: 8/22/2012 10:24 PM
Identification

NCPDPID NCPDP03

NPI NPI3300330

StoreName PHILLIPS PHARMACY

Address

AddressLine1 1600 21ST ST NW

City WASHINGTON

State DC

ZipCode 20009

Prescriber

Identification

NPI NPI9999999

ClinicName CORCORAN CLINIC

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Suffix MD

Address

AddressLine1 500 SEVENTEENTH ST NW

City WASHINGTON

State DC

ZipCode 20006

CommunicationNumbers

Communication

Number 2026391800

Qualifier TE

Scenario: 38: Census - Admission | with ALG and DIA | LTPAC | Martin Doe 

Header

To NCPDP04

From NPI9999999

MessageID CENSUS001

SentTime 2011-05-01T09:15:10

Body

Census

Request

ChangeRequestType A

CensusEffectiveDate 2011-05-01

Prescriber

Identification

NPI NPI9999999

DEANumber DEA999999

StateLicenseNumber LIC99999

ClinicName MOCA COMMUNITY

Name

LastName BALZARY

FirstName MICHAEL

MiddleName PETER

Prefix DR

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023426230

Qualifier TE

Facility

Identification

 © 1st American Systems and Services | www.1asas.com Page 204 of 206 Printed: 8/22/2012 10:24 PM
NPI NPI1234567

DEANumber DEA123456

FacilityName MOCA COMMUNITY

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

Patient 

DateOfBirth

Date 1923-11-12

Name

LastName DOE

FirstName MARTIN

Gender M

Address

AddressLine1 1054 31ST ST NW

City WASHINGTON

State DC

ZipCode 20007

CommunicationNumbers

Communication

Number 2023426230

Qualifier TE

PatientLocation

FacilityUnit WEST WING

Bed A

Room 330

Allergy

NoKnownAllergies N

SourceOfInformation C

EffectiveDate

Date 1991-01-02

AdverseEvent

ItemDescriptionLong FOOD ALLERGY

ItemNumber 414285001

CodeListQualifier LD

DrugProductCoded

ItemDescriptionLong PEANUT

ItemNumber QE1QX6B99R

CodeListQualifier UN

ReactionCoded

ItemDescriptionLong ANAPHYLAXIS

ItemNumber 91941002

CodeListQualifier LD

SeverityCoded

ItemDescriptionLong MODERATE TO SEVERE

ItemNumber 371924009

CodeListQualifier LD

DiagnosisGeneral

SourceOfInformation C

EffectiveDate

Date 2009-12-20

ProblemType

ItemDescriptionLong DIAGNOSIS

ItemNumber 282291009

CodeListQualifier LD

ProblemNameCoded

ItemDescriptionLong MIGRAINE

ItemNumber 37796009

CodeListQualifier LD

DiagnosisGeneral

 © 1st American Systems and Services | www.1asas.com Page 205 of 206 Printed: 8/22/2012 10:24 PM
SourceOfInformation C

EffectiveDate

Date 2010-09-10

ProblemType

ItemDescriptionLong DIAGNOSIS

ItemNumber 282291009

CodeListQualifier LD

ProblemNameCoded

ItemDescriptionLong MODERATE RECURRENT MAJOR DEPRESSION

ItemNumber 18818009

CodeListQualifier LD

 © 1st American Systems and Services | www.1asas.com Page 206 of 206 Printed: 8/22/2012 10:24 PM