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 LISA Phone 707-586-4831 Fax 707-646-0279
Primary
Complaint		 PANEL# 1901355
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		LOPEZ, MARIA 


10 N 4TH STREET
SALINAS, CA
93906
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
06159226 
 
12/10/2014 
 
Phone
(home/cell) 		831-442-2675  Phone
(work) 		  Birth Date 2/28/1956 


Adjuster Name


INS. Address 		LISA VARTY   

Employer Name


Address

 SOLEDAD STATE PRISON 


 
SCIF
PO BOX 3171
SUISUN, CA 94585 
Phone 707-586-4831  Fax 707-646-0279  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 		 


Defense Attorney
Address 		 
 

 

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