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Doug Hurst
Care Coordinator
← Referrals

Sean Donnelly

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Referral Document

File Name
donnelly-wc.pdf
Urgency
Routine
Created
6/25/2026, 9:20:00 AM

Patient Information

Name
Sean Donnelly
Date of Birth
1979-11-02
Phone
631-555-0188
Payer Type
WC

Insurance

Carrier
NYSIF
Insurance ID
WC-44213
Group
—

Referring Physician

Name
Dr. Ben Cohen
Practice
—
Phone
—

Clinical

Clinical Indication
Chronic low back pain, work-related lifting injury
Diagnosis Codes
M54.5

Modalities (1)

Lumbar Spine · MRI · W/O ContrastCPT 72148