RUN DATE: April 10, 2006            OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES/OHIO DEPARTMENT OF MENTAL HEALTH                PAGE:     1
REPORT NAME: RA.02B06370.N10006                          DIVISION OF MANAGEMENT INFORMATION SERVICES
                                                        MACSIS HEALTH CARE CLAIM PAYMENT/ADVICE 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: 04/03/2006
PAYER NAME: MH&RSB ALLEN AUGLAIZE HARDI       PAYEE NAME: FAMILY RESOURCE                               ADDL PAYEEID/NPI: 6370/9900006370

PT NAME: PATIENT NAME                        MEMBER ID (UCI): 1234567      DOB: 04/19/2006             GENDER:  F   Medicaid Number:  123456789876  

                                                               Provider
                                         C                     Filename                                              ERA    835 835 835
                                      C  F  Payer Clm Ctrl #   Other Clm ID   Proc Code   Service             Charge Rsn    Adj Adj Rmk               Payment
Patient Control #                     S  I  Member Plan        (Batch #)      Modifiers   Date     Units      Amount Code   Grp Rsn Cd    Adj Amt      Amount
-----------------                     -  -  -----------        ---------      ---------   ----     -----      ------ ----   --- --- --    -------      ------
12345678998765432