RUN DATE: June  5, 2006             OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES/OHIO DEPARTMENT OF MENTAL HEALTH                PAGE:     1
REPORT NAME: RJ.02B06370.N10006                          DIVISION OF MANAGEMENT INFORMATION SERVICES
                                                                     MACSIS REVERSAL REPORT

         This information is confidential and is protected by Sect. 42 CFR, Part 2, federal confidentiality rules. Further
 disclosure is prohibited by the
         federal rules unless expressly permitted by the written consent of the person to whom it pertains or as otherwise
 permitted by 42 CFR, Part 2.

SENDER ID: ALLEB                              RECEIVER ID/NPI: 006370  FAM RES-LIMA/9900006370          PRODUCTION DATE: 05/30/2006
PAYER NAME: ASHTABULA COUNTY ADAMH BD         PAYEE NAME: FAMILY RESOURCE                               ADDL PAYEEID/NPI: 6370/9900006370

PT NAME: PATIENT NAME                        MEMBER ID (UCI): 1234567      DOB: 06/25/2006             GENDER:  F   Medicaid Number: 123456789876

                                         C                                                        835 835  |===== Corrected Priority Payer Information =====|
Patient Control #                     C  F  Member     Proc Code   Service            Payment Err Adj Rmk  Car-
Payer Claim Control #                 S  I  Plan       Modifiers   Date      Units     Amount Cde Rsn Cd   rier  Policy Number   Group        Name
---------------------                 -  -  ----       ---------   ----      -----     ------ --- --- --   ----  -------------   -----        ----

12345678998765432                                        

                                                                     SUB TOTAL:      $ -00.01