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 2011-08-16 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		CESENA, RICHARD (W/C) 


29195 RIO VERDE DR.
SANTA NELLA, CA 95322

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
8451096 
 
02/27/1985 
548-62-7778 
Phone
(home/cell) 		209-592-3615  Phone
(work) 		408-854-3339 Verra (Daughter)  Birth Date 12/14/1944 


Adjuster Name


INS. Address 		Christine Stillwell   

Employer Name


Address

 CITY OF SAN JOSE 


 
Intercare
P.O. Box 579
Roseville, CA 95661 
Phone 916-677-2551  Fax 916-781-5522  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 		N/A 
Case Manager

Address 		N/A
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		N/A 


Defense Attorney
Address 		N/A 
 

 

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