﻿<!--TEDS Sample 12/03/2012-->
<PreEncounter>
	<SenderData ProviderName="ABC Inc" ProviderETIN="0123456789" BatchNumber="1"/>
	<DocumentFunction DocumentNumber="1-1" DocumentFunction="4" DMHID="######">
		<EpisodeCare Division="ADA" EnrollingProviderSiteName="ABC Inc" EnrollingProviderSiteID="123" AdmissionDateTime="yyyy-11-30 10:00 AM">
			<ProgramAssignment Program="ADACSTARGenEnh" ProgramFromDate="yyyy-11-30" ProgramFromTime="10:00" Status="1" LivingArrangement="11" ProgramLevel="3Basic">
				<TEDSProgAssign ProviderSiteID="1234" DateInfoReceivedfromConsumer="yyyy-11-30" PrimarySubstanceAbused="0401" PrimarySAFrequency="0" PrimarySARoute="2" PrimarySAAgeFirstUsed="19" SecondarySubstanceAbused="9996" SecondarySAFrequency="NA" SecondarySARoute="NA" SecondarySAAgeFirstUsed="NA" TertiarySubstanceAbused="9996" TertiarySAFrequency="NA" TertiarySARoute="NA" TertiarySAAgeFirstUsed="NA" TreatmentCounty="001" PsychologicalProblemIndicator="0" DevelopmentProblemIndicator="0" VeteranStatusIndicator="0" EnrolledInSchool="0" PriorDetox="00" PriorResidential="00" PriorOutpatient="00" NumberofArrests="00" NumberofDUIArrests="00" IncomeSource="2" PrimarySourcePayment="02" WeeklyIncomeCode="199" MonthlyIncomeAmt="1990" LegalStatus="3" LivingArrangement="11" Education="25" SpecialEducation="19" PrimaryHealthInsurance="02" MaritalStatus="2" EmploymentStatus="3" Occupation="33" SelfHelpFrequency="0" NumberOfChildrenInYourCare="02" ChildrenRemovedFromCustody="00" ReferredForTBTesting="1" TBTestDate="yyyy-11-01" ReceivedTBCounseling="0" TBTestPositive="2">
					<TEDSProgAssignPubAsst PublicAssistance="3"/>
					<TEDSProgAssignMeds MedicationPrescribed="00"/>
				</TEDSProgAssign>
			</ProgramAssignment>
		</EpisodeCare>
	</DocumentFunction>
	<DocumentFunction DocumentNumber="1-2" DocumentFunction="5" DMHID="######">
		<EpisodeCare Division="ADA" EnrollingProviderSiteName="ABC Inc" EnrollingProviderSiteID="123" AdmissionDateTime="yyyy-11-30 10:00 AM">
			<ProgramAssignment Program="ADACSTARGenEnh" ProgramFromDate="yyyy-11-30" ProgramFromTime="10:00" Status="1" LivingArrangement="11" ProgramLevel="3" ProgramLevelFromDate="yyyy-12-01" ProgramLevelFromTime="11:45">
				<TEDSProgAssign ProviderSiteID="1234" DateInfoReceivedfromConsumer="yyyy-12-01" PrimarySubstanceAbused="0401" PrimarySAFrequency="0" PrimarySARoute="2" PrimarySAAgeFirstUsed="19" SecondarySubstanceAbused="9996" SecondarySAFrequency="NA" SecondarySARoute="NA" SecondarySAAgeFirstUsed="NA" TertiarySubstanceAbused="9996" TertiarySAFrequency="NA" TertiarySARoute="NA" TertiarySAAgeFirstUsed="NA" TreatmentCounty="001" PsychologicalProblemIndicator="0" DevelopmentProblemIndicator="0" VeteranStatusIndicator="0" EnrolledInSchool="0" PriorDetox="00" PriorResidential="00" PriorOutpatient="00" NumberofArrests="00" NumberofDUIArrests="00" IncomeSource="2" PrimarySourcePayment="02" WeeklyIncomeCode="199" MonthlyIncomeAmt="1990" LegalStatus="3" LivingArrangement="11" Education="25" SpecialEducation="19" PrimaryHealthInsurance="02" MaritalStatus="2" EmploymentStatus="3" Occupation="33" SelfHelpFrequency="0" NumberOfChildrenInYourCare="02" ChildrenRemovedFromCustody="00" ReferredForTBTesting="1" TBTestDate="yyyy-12-01" ReceivedTBCounseling="1" TBTestPositive="1">
					<TEDSProgAssignPubAsst PublicAssistance="3"/>
					<TEDSProgAssignMeds MedicationPrescribed="00"/>
				</TEDSProgAssign>
			</ProgramAssignment>
		</EpisodeCare>
	</DocumentFunction>
	<DocumentFunction DocumentNumber="1-3" DocumentFunction="6" DMHID="######">
		<EpisodeCare Division="ADA" EnrollingProviderSiteName="ABC Inc" EnrollingProviderSiteID="123" AdmissionDateTime="yyyy-11-30 10:00 AM">
			<ProgramAssignment Program="ADACSTARGenEnh" ProgramFromDate="yyyy-11-30" ProgramFromTime="10:00" Status="2" ProgramToDate="yyyy-12-03" ProgramToTime="08:47">
				<TEDSProgAssign ProviderSiteID="1234" DateInfoReceivedfromConsumer="yyyy-12-02" PrimarySubstanceAbused="0401" PrimarySAFrequency="0" PrimarySARoute="2" PrimarySAAgeFirstUsed="19" SecondarySubstanceAbused="9996" SecondarySAFrequency="NA" SecondarySARoute="NA" SecondarySAAgeFirstUsed="NA" TertiarySubstanceAbused="9996" TertiarySAFrequency="NA" TertiarySARoute="NA" TertiarySAAgeFirstUsed="NA" TreatmentCounty="001" PsychologicalProblemIndicator="0" DevelopmentProblemIndicator="0" VeteranStatusIndicator="0" EnrolledInSchool="0" PriorDetox="00" PriorResidential="00" PriorOutpatient="00" NumberofArrests="00" NumberofDUIArrests="00" IncomeSource="2" PrimarySourcePayment="02" WeeklyIncomeCode="199" MonthlyIncomeAmt="1990" LegalStatus="3" LivingArrangement="11" Education="25" SpecialEducation="19" PrimaryHealthInsurance="02" MaritalStatus="2" EmploymentStatus="3" Occupation="33" SelfHelpFrequency="0" NumberOfChildrenInYourCare="02" ChildrenRemovedFromCustody="00" NumberOfChildrenReturned="00" ReferredForTBTesting="1" TBTestDate="yyyy-12-02" ReceivedTBCounseling="1" TBTestPositive="0">
					<TEDSProgAssignPubAsst PublicAssistance="3"/>
					<TEDSProgAssignMeds MedicationPrescribed="00"/> 
				</TEDSProgAssign>
			</ProgramAssignment>
		</EpisodeCare>
	</DocumentFunction>
</PreEncounter>

