SOUTH COUNTY PAIN & REHAB
Maureen D. Miner. M.D.
Diplomate, American Board of Physical Medicine & Rehabilitation
Diplomate, American Board of Pain Medicine
Sub-Specialty Board Certified, Spinal Cord Medicine
Qualified Medical Evaluator
 
  7091 Monterey St., Suite A
Gilroy, CA 95020
Phone: (408) 842-9296
FAX: (408) 842-6878
Date 2011-04-10 Physician MAUREEN D. MINER, MD
Caller VICTORIA FARIAS Phone 510-797-1819 Fax
Primary
Complaint		 PANEL #1186570
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		FARIAS, VICTORIA A. 


35289 CABRAL DRIVE
FREMONT, CA
94536
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
572989984 
UNASSIGNED 
04/10/2008 
572-89-9984 
Phone
(home/cell) 		510-797-1819 / 510-784-2187  Phone
(work) 		  Birth Date 10/23/1956 


Adjuster Name


INS. Address 		REBECCA PEREZ   

Employer Name


Address

 PG&E 


24300 CLAWITER ROAD
HAYWARD, CA 94545 
PG&E
P.O. BOX 7779
SAN FRANCISCO, CA
94120-7779 
Phone 415-973-4201  Fax 415-973-7828  Phone   Fax  
Appt. TYPE ✔ QME Panel   QME Re–Eval   QME
Applicant		   AME   Med legal   Consult ONLY   Consult&Treat   EMG/NCS
Appt. DATE: 2011-03-03  Appt. TIME 11:00AM 
Interpreter required? ✔ No   Yes Agency/Language   

Referring Physician
Address 		N/A 
Case Manager

Address 		N/A
N/A  N/A 
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		N/A 


Defense Attorney
Address 		N/A 
 

 

Phone   Fax   Phone   Fax  
PROVIDE MEDICAL RECORDS 3 weeks IN ADVANCE
PLEASE DO NOT SEND ORIGIANALS OR CD’S
NO SHOW FEE: $300.00
  
ACKNOWLEDGE ABOVE WITH YOUR INITIALS_____
AND FAX BACK TO OUR OFFICE. THANK YOU