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 2016-05-26 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		GREENFIELD, SANDRA / SIBTF 


185 BRIGGS RANCH DRIVE
FOLSOM, CA 95630

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
NG197340 
ADJ7179087 
11/29/2005 
556-74-9300 
Phone
(home/cell) 		408-446-3889  Phone
(work) 		  Birth Date 04/22/1951 


Adjuster Name


INS. Address 		JOE VILLEZAR   

Employer Name


Address

  


 
SIBTF CLAIMS
160 PROMENADE CIRCLE, SUITE 350
SACRAMENTO, CA 95834 
Phone   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 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		ARTHUR L. JOHNSON, ESQ. 


Defense Attorney
Address 		EVAN ADAMS, ESQ 
BUTTS & JOHNSON 
675 N. FIRST STREET, SUITE 975
SAN JOSE, CA 95112 		OD LEGAL 
PO BOX 420603
SAN FRANCISCO, CA 94142
Phone 408-293-4818  Fax 408-293-3478  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