<ns0:Confirmation SAM2_Number="43555782925" Number_Of_Transactions="1" Total_Billed="100.00" xmlns:ns0="http://ConfirmationForm.confirmation">
  <Claim Claim_ID="123456" DMH_ID="78932" ConsumerName="Berhorst, Hope">
    <Service SVC_ID="1" DateOfService="20060810" Payer_Determine="Medicaid" Service_Category="ADACSTARAd" Contract_Number="ADA-CDA123456" Site="Fulton" BilledAmt="100.00" Return_Acc_Rej="Accepted" Error_Desc="" />
  </Claim>
</ns0:Confirmation>