MMlii:f.!_earwa LLLJ:EliR~Y~.p *:: * :~n -}*~*:** ¥-u ~t i~oc_!n~s JLJL~C~• J8[12!6~W~A~S H~I N!JG~TCJO~N:!.__BR~D~S~T E~1 .Q.0l._2 L-• 1WLJE~S~T J!MUl!NiS T!_E~RLJM!_!;DU2111J1 5~7[:-JS>l.717!9 _

, R1co D (id #1121357, dob: 12/14/1973)

(!o Provider

Phone:

Fax:

Imaging 02/27/JI 2023 From Order Provider

TODD RUTH, MD

Westminster In Office

826 WASHINGTON RD STE 102

WESTMINSTER, MD 21157-5779

Phone: 850-***-****

..__ __J Fax: 833-***-****

[Diagnosis

Order Name

Imaging Order Information

II Neck pain

ICD-10: M54.2: Cervicalgia

II

Orders Included: 1

Neck pain I ICD-10: M54.2: Cervicalgla

• XR, CERVICAL SPINE, 2 OR 3 VIEW

NOTE TO l~GING FACILITY: image of lead placement

Patient Information

/ Patient Name II MILLER, RICO D

/ Sex - DOB - Age II M 12/14/1973 49yo

I Address 17018 WOODST,REAM TERRACE

LANHAM, MD 20706

I Phone H: M: ((864) 864) 438-***-**** 8519 I

7

I Primary Insurance None recorded. j

L-s_1 e_c_o_nd_a_ry_ln_s_u_ra_n_c_e __,,L-N_o_n_e_re_c_o_rd_e_d_. JI[] Electronically Signed by: TODD RUTH, MD

TODD RUTH, MD

7

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