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 2016-10-12 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint		 BACK-INCLUDING BACK MUSCLES, SPINE/SPINE CORD
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		MONTOYA, ALEJANDRO 


1141 FOSTER CITY BLVD, APT 3
FOSTER CITY, CA
94404
Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
 
ADJ10380392 
7/01/2015 
 
Phone
(home/cell) 		650-954-0457  Phone
(work) 		  Birth Date 10/31/1993 


Adjuster Name


INS. Address 		LISA ARMENDAREZ   

Employer Name


Address

 ESPETUS 


710 SOUTH B ST
SAN MATEO, CA
94401 
THE HARTFORD
PO BOX 14475
LEXINGTON, KY
40512 
Phone 866-401-9222  Fax 888-459-1621  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 		WENLEI JOHNSON, ESQ. DARLENE SHARP GOLD RIVER 
 

PO BOX 2282 
BREA, CA
92882
Phone   Fax   Phone 714-674-1000  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