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["Form GNOCHC-1",{"$nulls":46},4,"T1015","04 - Homeless Shelter ","T1015 - Primary Care"]
["Enrollee Encounter Data ",{"$nulls":46},11,"T1015 TF","11 - Office ","T1015 TF - Basic Behavioral Health"]
["Quarterly Report",{"$nulls":46},12,"T1015 TG","12 - Home ","T1015 TG - Serious Mental Illness Behavioral Health"]
[{"$nulls":47},15,null,"15 - Mobile Unit "]
["GNOCHC Prov. Org. Name:",null,null,null,"GNOCHC Provider ID (7 digit):",null,0,{"$nulls":40},49,null,"49 - Independent Clinic "]
["Site Name:",null,null,null,"GNOCHC NPI",null,0,{"$nulls":40},50,null,"50 - Federally Qualified Health Center "]
["Address",null,null,null,"Medicaid Prov. Number:",null,0,{"$nulls":40},53,null,"53 - Community Mental Health Center "]
[{"$nulls":4},"Medicaid NPI",null,0,{"$nulls":40},57,null,"57 - Non-Residential Substance Abuse Treatment Facility "]
["City, Zip",null,null,null,"Report Beginning Date:",null,"2010-10-01",{"$nulls":40},71,null,"71 - State or Local Public Health Clinic"]
["Phone",null,null,null,"Report Ending Date:",null,"2010-12-31",{"$nulls":40},72,null,"72 - Rural Health Clinic "]
[{"$nulls":47},81,null,"81 - Independent Laboratory"]
[]
["Patient SSN                  (XXXXXXXXX)","Patient Date of Birth","Patient Date of Service","Patient Last Name","Patient First Name","GNOCHC Enrollee ID Number ","Place of Service","Procedure Code (CPT 11/HCPCS List all)","Modifier TF or TG","Diagnosis Codes (Up to Six ICD 9 CM)","NDC for Drugs and Biologicals Administered by Physician ","Days/Units","Charges","Attending Provider","Attending Provider NPI","Signature and Date for Encounter Line (Not Detail Lines)","Unknown to MEDS","Known to MEDS","Type Case(s)","Type Case(s) Start Date(s)","Active in MEDS on Date of Service ","TPL ","Source of Application","Application Center ID if applicable","Known Inactive MEDS","Known Rejected in MEDS","Rejection Code"]
[111111111,"2018-09-30","2011-07-01","Jones","Gloria",2222226666666,53,"T1015","TF",296.3,null,1,300,"XXXXXXX","XXXXXXXXXX"]
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[{"$nulls":7},80100,null,250,null,1,50]
[{"$nulls":7},"H0033",null,null,null,2,100]
[]
[222222222,"1965-10-20","2011-01-06","Smith","Chris",8888887777777,12,"T1015",null,493.92,null,1,240,"XXXXXXX","XXXXXXXXXX"]
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[{"$nulls":7},71035,null,null,null,1,25]
[{"$nulls":7},"G8292",null,null,null,1,40]
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[]
[222222222,"1965-10-20","2011-01-06","Smith","Chris",8888887777777,53,"T1015","TG",296.1,null,1,275,"XXXXXXX","XXXXXXXXXX"]
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