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 2015-05-31 Physician MAUREEN D. MINER, MD
Caller FRANDY KELLY AT LEARNING SERVICES Phone Fax
Primary
Complaint		 TBI
  Workers Compensation   Private Insurance   Medicare /2ndInsurance ✔ Self- Pay
Patient’s
Name


Address 		FRENCH, DANIEL 


10855 DEBRUIN WAY
GILROY, CA
95020
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
 
MVA 05/10/2014 
 
Phone
(home/cell) 		408-848-4379  Phone
(work) 		  Birth Date 12/07/1975 


Adjuster Name


INS. Address 		PRIVATE PAY   

Employer Name


Address

  


 
MICHAEL MARQUES (CONSERVATOR)
EL DORADO CO PUBLIC GUARDIAN
929 SPRING STREET
PLACERVILLE, CA 95667 
Phone 530-621-6312  Fax   Phone   Fax  
Appt. TYPE   QME Panel   QME Re–Eval   QME
Applicant		   AME   Med legal   Consult ONLY   Consult&Treat   EMG/NCS
Appt. DATE: 0000-00-00  Appt. TIME  
Interpreter required?   No   Yes Agency/Language   

Referring Physician
Address 		N/A 
Case Manager

Address 		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