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 2016-06-16 Physician MAUREEN D. MINER, MD
Caller KATHY Phone 818-575-2774 Fax
Primary
Complaint		 WRIST- PANEL# 7045886
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		SAUCEDA, GUADALUPE 


501 S GREEN VALLEY #49
WATSONVILLE, CA
95076
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
00047653 
 
10/05/2015 
549-97-6487 
Phone
(home/cell) 		831-359-3963  Phone
(work) 		  Birth Date 7/15/1966 


Adjuster Name


INS. Address 		LAURIE GABRIEL   

Employer Name


Address

 SALUD PARA LA GENTE 


 
PACIFIC COMPENSATION INS. CO.
PO BOX 5042
THOUSAND OAKS, CA 91359 
Phone 818-575-2753  Fax 818-575-8575  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 		RUCKA, OBOYLE, LOMBARDO & MCKENNA 


Defense Attorney
Address 		 
119 EAST BEACH ST 
WATSONVILLE, CA
95076 		 

Phone 831-728-4200  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