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 2016-06-03 Physician MAUREEN D. MINER, MD
Caller JORDAN Phone 858-503-4853 Fax
Primary
Complaint		 LEFT SHOULDER-THORACIC AND CERVICAL SPINE-- PANEL #7041347
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		KAUFFMAN, JACOB  


51 PIEDRAS BLANCAS
CARMEL VALLEY, CA
93924
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
30153817754-0001 
 
4/10/2015 
�&# 
Phone
(home/cell) 		831-238-6402  Phone
(work) 		  Birth Date 09/10/1981 


Adjuster Name


INS. Address 		TAMARA STEARNS   

Employer Name


Address

 HODGES RENTAL ALL 


 
SEDGWICK 14779 SAN DIEGO
PO BOX 14779
LEXINGTON, KY 40512 
Phone 858-503-4853  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 12:00PM 
Interpreter required? ✔ No   Yes Agency/Language   

Referring Physician
Address 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		DIRK STEMERMAN 


Defense Attorney
Address 		 
RUCKA OBOYLE MONTEREY 
1035 5TH STREET, STE B
MONTEREY, CA93940 		 

Phone 831-443-1051  Fax 831-443-6419  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