Brian Torres

 
 LOUISIANA PAIN 
 SPECIALISTS 
 PAIN DIAGNOSIS & INTERVENTION EXPERTS 
 RADIOLOGY ORDER 
 PATIENT DEMOGRAPHICS 
 GUARANTOR & INSURANCE INFORMATION 
 Patient: John Long
 Insurance:VA CCN OPTUM 
 DOB: 1999-07-02 Age: 71 year Sex: Male 
 Guarantor: John Long 
 Address: 4129 1ST AVE Bay Saint Louis MS 39529
 Policy# 422983729 
 
 Group# 
 RAD VENDOR DETAILS 
 ORDERING PHYSICIAN DETAILS 
 Rad Name: 
 Ordering Physician Name: Suneil Jolly MD 
 Address: 
 Order#: RAD23829 
 Phone: 
 Fax: 
 Order Date: 2020-07-04
 Sr.No. 
 Test Name 
 Test Status CPT Code ICD Code Instructions 
 M54.5; 
 1 
 X-ray Lumbar Spine 5 views 
 Routine 
 72110 
 M47.897; 
 M47.27 
 M47.27; 
 MRI Lumbar Spine without contrast 
 
 Comments: 
 S Idly 
 Suneil Jolly MD 
 This has been electronically signed on 2020-22-03.
