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 2015-02-28 Physician MAUREEN D. MINER, MD
Caller EVELYN (ADJ's ASST) CALLED TO SET PQME APPT. Phone 866-682-6671 Fax 866-461-2934
Primary
Complaint		 PANEL #7019430
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		HERNANDEZ, TRINIDAD 


745 LINE STREET
HOLLISTER, CA, 95023

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
2014222409 
UNASSIGNED 
01/19/2014 
 
Phone
(home/cell) 		831-537-6655  Phone
(work) 		  Birth Date 06/08/1976 


Adjuster Name


INS. Address 		DANIELLE DUGGER   

Employer Name


Address

 ALLISON JEAN INC 


 
EMPLOYERS INSURANCE
P.O. BOX 539004
HENDERSON, NV 89053 
Phone 888-682-6671  Fax 866-461-2934  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  ADJ's ASST. SAID THEY WOULD ARRANGE 

Referring Physician
Address 		N/A 
Case Manager

Address 		N/A
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		JOHN AMOS, ESQ., AMOS DITTRICH & USHANA ATTORNEYS AT LAW 


Defense Attorney
Address 		N/A 
1184 MONROE STREET SUITE 6 
SALINAS, CA 93906
 

Phone 831-442-7232  Fax 831-676-0339  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