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 2011-06-01 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		CASTILLO, GAIL 


3275 PORT PACIFIC LANE
ELK GROVE, CA
95758
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
0045438-98300033 
 
03/07/1997 
552-72-5949 
Phone
(home/cell) 		408-843-6369  Phone
(work) 		  Birth Date 11/17/1947 


Adjuster Name


INS. Address 		SARA L. KERLEY   

Employer Name


Address

 AT&T 


 
SARA L. KERLEY, INC.
3450 SACRAMENTO ST., STE. 234
SAN FRANCISCO, CA 94118
sara@sarakerlye.com 
Phone 415-674-7704  Fax 310-822-8881  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 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		hwarkins@mpbf.com (Paul's atty) 


Defense Attorney
Address 		 
(forward billing to atty) 

 

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