<?xml version="1.0" encoding="UTF-8"?>
<PreEncounter>
	<SenderData ProviderName="My Org" ProviderETIN="94203283999" BatchNumber="####0504-005"/>
	<DocumentFunction DocumentNumber="####0504-005-001" DocumentFunction="2" DMHID="######">
		<ConsumerData>
			<Race White="0" Black_AfricanAmerican="0" Asian="1" NativeHawiian_PacificIslander="0" AmIndian_NativeAlaskan="0" OtherRace="0" NotOfHispanicOrigin="1" Hispanic_Mexican="0" Hispanic_Cuban="0" Hispanic_PuertoRican="0" OtherHispanic="0"/>
		</ConsumerData>
		<EpisodeCare Division="MRDD" EnrollingProviderSiteName="Jeff City" EnrollingProviderSiteID="413" AdmissionDateTime="yyyy-04-05 12:00" AdmissionReason="1" ReferralSource="51" FamilySize="1">
			<Commitments CommitmentType="200" CommitmentFromDate="yyyy-04-05" CommitmentCounty="033" PrimaryIndicator="1"/>
		</EpisodeCare>
	</DocumentFunction>
</PreEncounter>
