Jacob Garcia

 
 LOUISIANA PAIN 
 SPECIALISTS 
 PAIN DIAGNOSIS & INTERVENTION EXPERTS 
 RADIOLOGY ORDER 
 PATIENT DEMOGRAPHICS 
 GUARANTOR & INSURANCE INFORMATION 
 Patient: Lee Hernandez
 Insurance:VA CCN OPTUM 
 DOB: 1997-05-08 Age: 71 year Sex: Male 
 Guarantor: Lee Hernandez 
 Address: 4162 1ST AVE Bay Saint Louis MS 39562
 Policy# 426283762 
 
 Group# 
 RAD VENDOR DETAILS 
 ORDERING PHYSICIAN DETAILS 
 Rad Name: 
 Ordering Physician Name: Suneil Jolly MD 
 Address: 
 Order#: RAD23862 
 Phone: 
 Fax: 
 Order Date: 2019-02-10
 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 2018-06-28.
